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The Journal of the Connecticut State Medical Society 



Barry A. Eagel, Bernard Vino ski, 
and David Krugman 

Steven C. Sieber, Nelson A. Gelfman, 
Ronald Dandurand, and Frank Braza 

Maria P. Lenaz and Richard Z. Belch 

Epitomes of Progress 





Reye’s Syndrome in an Adult 

Ectopic ACTH and Adrenal Myelolipoma 

St Ack& 

Adenocarcinoma of the Cervix Arising in Pregnancy 
Important Advances in Clinical Medicine: Pediatrics 

special articles: 

AM A Council on Scientific Affairs 


National Institutes of Health 
Centers for Disease Control 
James E. Bryan 
Henry Schneiderman 
Julius Landwirth 
Robert J. Brunell 








Treatment of Obesity in Adults 

Consensus Conference 

Urinary Incontinence in Adults 


Epidemiologic Notes and Reports 
View from the Hill 

Rules for Surviving a Chief Medical Residency 
Cost-Containment and Medical Malpractice 
CSMS-1988: The Society’s Year in Review 

FEB 24 1989 

JiOI 10 CIRC. 


David P. Johnson 53 

Reye’s Syndrome 


The President’s Page 

Norman A. Zlotsky 57 The 1989 Legislature and Us 

Robert U. Massey 59 

Joseph M. Healey 60 

Reflections on Medicine 

Emil von Behring and Diphtheria 

St ACKs 

Law, Medicine and Public Policy 

The McConnell Case and the “Death with Dignity Statute” 

Richard M. Ratzan 54 
Andrew D. Weinberg 55 

Letters to the Editor 

Letters of Reference and Hospital Appointments 
Call to Arms 


44 Around the State 
56 Book Review 

61 Obituary — Frederick C. Weber, Jr. 1911-1988 

62 Physician Placement Service 

Owned, Published and Copyrighted, ©1988 by the Connecticut State Medical Society 

CONNECTICUT MEDICINE (ISSN 0010-6178), published monthly at 160 St. Ronan St., New Haven, CT 06511 
Subscription rate included in membership dues. Non-members: $25.00 per year. Second-class postage paid at New Haven, CT 
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Barry A. Eagel, Bernard Vinoski, 
and David Krugman 

Steven C. Sieber, Nelson A. Gelfman, 
Ronald Dandurand, and Frank Braza 

Maria P. Lenaz and Richard Z. Belch 

Epitomes of Progress 





Reye’s Syndrome in an Adult 

Ectopic ACTH and Adrenal Myelolipoma 

s TAqc$, 

Adenocarcinoma of the Cervix Arising in Pregnancy 
Important Advances in Clinical Medicine: Pediatrics 

special articles: 

AM A Council on Scientific Affairs 


National Institutes of Health 
Centers for Disease Control 
James E. Bryan 
Henry Schneiderman 
Julius Landwirth 
Robert J. Brunell 








Treatment of Obesity in Adults 

Consensus Conference 

Urinary Incontinence in Adults 

Epidemiologic Notes and Reports 


FEB 24 1989 

View from the Hill SEC'l HOI 10 CtRG. 

Rules for Surviving a Chief Medical Residency 

Cost-Containment and Medical Malpractice 

. I 

CSMS-1988: The Society’s Year in Review 


David P. Johnson 53 

Reye’s Syndrome 


The President’s Page 

Norman A. Zlotsky 57 The 1989 Legislature and Us 

Robert U. Massey 59 

Joseph M. Healey 60 

Richard M. Ratzan 54 

Andrew D. Weinberg 55 

Refections on Medicine 

Emil von Behring and Diphtheria 

Law, Medicine and Public Policy 

The McConnell Case and the “Death with Dignity Statute 


Letters to the Editor 

Letters of Reference and Hospital Appointments 

Call to Arms 

general: 44 Around the State 

56 Book Review 

61 Obituary —Frederick C. Weber, Jr. 1911-1988 

62 Physician Placement Service 

Owned, Published and Copyrighted, ©1988 by the Connecticut State Medical Society 

CONNECTICUT MEDICINE (ISSN 0010-6178), published monthly at 160 St. Ronan St., New Haven, CT 06511 
Subscription rate included in membership dues. Non-members: $25.00 per year. Second-class postage paid at New Haven, CT 
POSTMASTER: Send address changes to 160 St. Ronan St., New Haven, CT 06511 

Digitized by the Internet Archive 
in 2016 with funding from 

The National Endowment for the Humanities and the Arcadia Fund 


Dale G. Senior, Karen L Waters, 
Mark Cassidy, Tom Crucitti, Howard Shapiro, 

and Arthur L. Riba 

67 Effect of Aerobic Training on Left Ventricular Diastolic Filling 

Elinor S. Kron, Harold Moskowitz, 71 
Dorothy Me Conner, and Julia Ann Loveland 

American College of Physicians, 73 
Connecticut Chapter 

Epitomes of Progress 75 

Mobile Mammography: The First Six-Months Experience at 
Mount Sinai Hospital 

Abstracts by Residents and Fellows 
Important Advances in Clinical Medicine — Pathology 

special articles: 

Leroy H. Wardner 

AM A Council on Long Range Planning 
and Development 

James E. Tisdale 
Mary B. Prybylo and Robert D. Stein 
Stewart J. Petrie 
James E. Bryan 


Dewees H. Brown 
J. Michael Eisner 


85 The World’s Longest Insulin Patient un1V ersity of Maryland 
91 The Future of Family Practice Baltimore 





Drug Information Update MAR 

Combination Antiarrhythmic Therapy 

The Connecticut State Joint Practice$56ifimittee 
Shoot Out at the RBRVS Corral 


View from the Hill 

20 1989 
m io giro. 

115 Family Practice 

116 Informed Consent and Common Sense 


Norman A. Zlotsky 117 

Robert U. Massey 119 

Joseph M. Healey 121 

Russell V. Fuldner 123 
Timothy B. Norbeck 125 

The President’s Page 

Reform from Within 

Reflections on Medicine 

Too Much Science? 

Law, Medicine and Public Policy 

Winter Reading: The Past and Future of Health Law 

Letter to the Editor 

Life After... 

From the Executive Director’s Office 





Book Review 
Around the State 

In Memoriam 

Physician Placement Service 

Owned, Published and Copyrighted, ©1989 by the Connecticut State Medical Society 

CONNECTICUT MEDICINE (ISSN 0010-6178), published monthly at 160 St. Ronan St., New Haven, CT 06511 
Subscription rate included in membership dues. Non-members: $25.00 per year. Second-class postage paid at New Haven, CT 
POSTMASTER: Send address changes to 160 St. Ronan St., New Haven, CT 06511 







Ira Schlesinger 
Alan K. Meinke, M.D. 

Steven T. Ruby, Jonathan Kramer, 
Suzanne B. Cassidy, and Petros Tsipouras 

special articles: 

Matthew L. Cartter, Patricia Mshar 
and Harold Burdo 

Robert S. Walzer 
Daniel Callahan 
Edward L. Schneider 
Linda J. Schofield 

Joseph P. Newhouse, Geoffrey Anderson, 
and Leslie L. Roos 

Samuel A. Mitchell 
Pete Stark 


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Michale L. Friedland 
Stanley B. Weld 


Norman A. Zlotsky 


Connecticut State Medical Society 









Robert G. Evans 168 

Victor R. Euchs 172 






Robert U. Massey 187 

Joseph M. Healey 189 

Anthony S. Morgan 
Timothy B. Norbeck 
M.D. Health Plan 

Ataxia Telangiectasia: A Familial Multisystem Disorder 
Pancreatic Tuberculous Abscess 

Internal Carotid Artery Aneurysm: A Vascular Manifestation of 
Type IV Ehlers-Danlos Syndrome STACKS 

145 The Epidemic Hysteria Dilemma 








Legal Aspects of Employing “Counselors” in a Clinical Practice 
Old Age and New Policy 

Options to Control the Rising Health Care Costs of Older Americans 
To All Connecticut Physicians: Procedures for Screening 
Nursing Home Applicants 

Hospital Spending in the United States and Canada: A Comparison 

Perspectives Canada: 

Split Vision: Interpreting Cross-Border Differences in 
Health Spending 

Perspectives: United States 
Learning from the Canadian Experience 
Defending the U.S. Approach to Health Spending 
Fixing an Inefficient System 

Residency Requirements in Medicine and the Community Hospital 
A Full Time Secretary 

The President's Page 

RBRVS: Continued 

Refections on Medicine 

Telling the Tall Tales ' '1* / 

Law, Medicine and Public Policy 

Winter Reading: Legal Resolution of the Health Care System 

Letter to the Editor 

In Favor of Bill 413: Helmet Law 

From the Executive Director’s Office 
Doctor-Owned HMO Takes Off 

Book Review 

Physician Placement Service 

Around the State 

197th Annual Meeting Program 

Owned, Published and Copyrighted, ©1989 by the Connecticut State Medical Society 

CONNECTICUT MEDICINE (ISSN 0010-6178), published monthly at 160 St. Ronan St., New Haven, CT 06511 


* CUI ^ 


The Journal of the Connecticut State Medical Society 


APRIL 1989 



Colleen Brophy and John Seashore 203 
John P. Koulos and James S. Hoffman 207 

Peter K. Schauer, William Agostinucci, 211 
Richard Gannon, and Annelieke R. Schauer 

Epitomes of Progress 217 

special articles: 

Henry R. Kranzler 225 

AM A Council on Scientific Affairs 229 

The Medical Letter 237 

James E. Bryan 239 


Norman A. Zlotsky 241 

Robert U. Massey 243 

Joseph M. Healey 245 

Timothy B. Norbeck 249 

Meckel’s Diverticulum in the Pediatric Surgical Populat^^^^^^ 

Dysgerminoma: A Study of 13 Cases from the 
Connecticut Tumor Registry 

Practical Aspects of Pain Management in Cancer Patients 
Important Advances in Clinical Medicine — Plastic Surgery 

Boswell’s Affective Illness: A Reappraisal 

Drugs for Parkinsonism 
View from the Hill 

Health sciences librae 


JUN.vl 1989 

The President’s Page 

Anabolic Steroids and Athlete£EC'Ui $01 10 CIRC, 

Reflections on Medicine 

Successful Surgery 

Law, Medicine and Public Policy 

Refusing Life-Sustaining Technology: The McConnell Case 
From the Executive Director’s Office 

general: 247 

Book Review 


Around the State 


Information for Authors 


In Memoriam 



Physician Placement Service 

Owned, Published and Copyrighted, ©1989 by the Connecticut State Medical Society 

CONNECTICUT MEDICINE (ISSN 0010-6178), published monthly at 160 St. Ronan St., New Haven, CT 06511 
Subscription rate included in membership dues. Non-members: $25.00 per year. Second-class postage paid at New Haven, CT. 
POSTMASTER: Send address changes to 160 St. Ronan St., New Haven, CT 06511 

1 4t£U 


Pradip M. Pathare and Richard E. Peschel 263 
Nabil M.K. Ali and James S. Hoffman 266 

Raymond Squier, Jeffrey S. Morrow, 269 
and Robin Roman 

,TACK s 

Epitomes of Progress 272 

special articles: 

Joseph L. Belsky 279 

Aric Schichor, Mary Kelly Lombardo, 281 
Leonard I. Banco, and Robert A. Kramer 

Centers for Disease Control 285 
Robert Mulhausen and Jeanne McGee 293 
The Medical Letter 299 


James E. Bryan 303 

Is Adjuvant Systemic Therapy Necessary for All Axillary Node 
Negative Breast Cancer Patients? St &ck$ 

Tolerance During Long-Term Administration of 
Intrathecal Morphine 

Pain Therapy for Pancreatic Carcinoma with Neurolytic Celiac 
Plexus Block 

Important Advances in Clinical Medicine — Allergy and Immunology 

Care of Irreversibly 111 Patients: Policy Statement of the 
Connecticut Chapter of the American College of Physicians 

Are Physicians Meeting the Needs of Their Adolescent Patients? 

Risks Associated with Human Parovirus B19 Infection 
Physician Need 

Drugs for Epilepsy i 

Insect Repellents 
View from the Hill 



Lawrence C. Kleinman 305 

8 E 













i I 

s a 



Francis G. Blake 307 
Norman A. Zlotsky 309 
Robert U. Massey 311 

* Joseph M. Healey 312 

Semantics As Substance: Life Support Systems or Medically Invasive 

Fifty Years Ago 


The President’s Page 


Reflections on Medicine 

A Simpler, Kinder System 

Law, Medicine, and Public Policy 

Examining the McConnell Decision 


general: 315 Physician Placement Service 

Owned, Published and Copyrighted, ©1989 by the Connecticut State Medical Society 

CONNECTICUT MEDICINE (ISSN 0010-6178), published monthly at 160 St. Ronan St., New Haven, CT 06511 
Subscription rate included in membership dues. Non-members: $25.00 per year. Second-class postage paid at New Haven, CT 
POSTMASTER: Send address changes to 160 St. Ronan St., New Haven, CT 06511 



JUNE 1989 


Special Issue: Lyme Disease 
Matthew L. Cartter, M.D., Guest Editor 


Matthew L Cartter 319 Lyme Disease 

Matthew L Cartter, Patricia Mshar, 320 The Epidemiology of Lyme Disease in Connecticut 
and James L Hadler 


Theodore F. Tsai, Raymond E. Bailey, 


David H. 

and Patrick S. Moore 
Trot^k, Joseph E. Craft, 


and Daniel W. Rahn 
Louis A. Magnarelli 


Robert T. Schoen 



istello, Allen C. Steere, 


Ronald E. P Q 

id Henry M. Feder, Jr. 

Me, t-* 

rtter, James L. Hadler, 


Mich: §5 

, and Lynne Mofenson 

John F. Anderson 


Kirby C. Stafford, III ' 



Steven A. Levy 



iter, Thomas A. Farley, 



Q 3 

o, and James L Hadler 

ipecial articles: 

Joel Lang 



Polly Murray 


Nancy L. Considine 


National Surveillance of Lyme Disease, 1987-1988 

Clinical Manifestations of Lyme Disease in the United States 

Laboratory Analyses for Lyme Disease 
Treatment of Lyme Disease 

A Prospective Study of Tick Bites in an Endemic Area 

for Lyme Disease 

Lyme Disease and Pregnancy 

Ecology of Lyme Disease 

Lyme Disease Prevention: Personal Protection and Prospects 
for Tick Control 

Lyme Borreliosis in Domestic Animals 

Lyme Disease Prevention — Knowledge, Beliefs, and Behaviors 
among High School Students in an Endemic Area 

A History of Lyme Disease 

Catching the Bug: How Scientists Found the 


use of Lyme Disease 

A Message to Physicians 

Sharing the Task of Lyme Disease: Public Education 


Roger S. Beck 367 

Robert U. Massey 371 

Nancy Williams 373 

Donald P. Buebendorf Christopher W. Goff 375 
and Kenneth R. Burke 

The President’s Page 

The Year Ahead 

Reflections on Medicine 

Connecticut’s Epidemics 

Law, Medicine and Public Policy 

Legal Implications of Uncertainty in Lyme Disease 

Letters to the Editor 

Practicing in Lyme Disease Territory 

Charles H. Robinson 375 
Tuula Fabrizio 376 
Keith Sinusas and Michael Kazak off 376 
Matthew L. Cartter, James L. Hadler, 376 
Valerie J. Rhodes and Lyle R. Peterson 

Ode to that Damm ini Ixodes 
Lyme Disease and Antibiotic Prophylaxis 
A Study of Early Lyme Disease Treatment 
Reinfection with Borrelia Burgdorferi 

Eugene D. Shapiro and Michael A. Gerber 377 

Sam T. Donta 377 
Timothy B. Norbeck 381 
Norman A. Zlotsky 383 
Roger S. Beck 385 
Guy W. Van Syckle 387 

general: 379 


Lyme Disease Clinical Trial 

New Lyme Disease Clinic at UConn Health Center 
CSMS House of Delegates — Annual Meeting 
Address of the President 
Inaugural Address of the Incoming President 
News From the CSMS-IPA 

Book Review 

Physician Placement Service 


Owned, Published and Copyrighted, ©1989 by the Connecticut State Medical Society 

CONNECTICUT MEDICINE (ISSN 0010-6178), published monthly at 160 St. Ronan St., New Haven, CT 06511 
Subscription rate included in membership dues. Non-members: $25.00 per year. Second-class postage paid at New Haven, CT 
POSTMASTER: Send address changes to 160 St. Ronan St., New Haven, CT 06511 




Reye’s Syndrome in an Adult 


ABSTRACT— There have been over 3,500 cases of 
Reye’s syndrome reported to the CDC since 1973. The 
temporal use of aspirin with a prodromal viral illness has 
been statistically associated with the etiology of the syn- 
drome. Reye’s syndrome presents as an acute progressive 
encephalopathy with varying levels of coma and normal 
cerebrospinal fluid (CSF). Hepatic transaminases are 
elevated, and the serum aspartate aminotransaminase 
(AST) is usually elevated three to 30 times normal. Histo- 
logical changes on liver biopsy are characterized by 
microvesicular intrahepatocyte lipid deposition, which is 
rarely found in other diseases. 

The syndrome has rarely been reported to occur in 
adults over 18 years old. We report the 25th case of 
Reye’s syndrome occurring in an adult, which initially 
presented as acetominophen toxicity but was shown to 
be Reye’s syndrome on histological examination of the 

R EYE’S syndrome (RS) is a well characterized clin- 
ical entity consisting of a prodromal viral illness, 
followed in three to five days by vomiting, altered levels 
of consciousness, noninflammatory encephalopathy, and 
hepatic dysfunction. There have been over 3,000 cases 
reported to the Centers for Disease Control since 1973. 1 
However, there are only 20 previously reported cases in 
the literature of occurrence in the adult population. 
Aspirin (acetylsalicylic acid) ingestion has been statistic- 
ally associated with prodromal viral illness in the eti- 
ology of Reye’s syndrome. We report a case of adult RS 
which was complicated by concomitant acetaminophen 

Case Report 

A 26-year-old white male with a history of paranoid 
schizophrenia and a suicide attempt with thioridazine 
(Mellaril) in 1982, was brought into the New Britain 
General Hospital Emergency Room at 7:00 p.m. on 24 

BARRY A. EAGEL, M.D., Senior Resident, Department of 
Medicine, New Britain General Hospital. BERNARD VINOSKI, 
M.D., Chief Resident, Department of Medicine, New Britain General 
Hospital. DAVID KRUGMAN, M.D., Chief, Department of Path- 
ology, New Britain General Hospital, New Britain, CT; Associate 
Professor of Pathology, Department of Pathology, University of Con- 
necticut School of Medicine, Farmington, CT. 

Reprints request to: Department of Pathology, New Britain General 
Hospital, 100 Grand St., New Britain, CT 06050 (Dr. Krugman). 

January 1987 after ingestion of about 30 acetaminophen 
(Tylenol) tablets (9.75g) in an apparent suicide attempt. 
He had been taking chlorpromazine (Thorazine) and 
trihexyphenidyl hydrochloride (Artane), and had also 
been taking an unknown quantity of aspirin and bismuth 
subsalicylate (Pepto-Bismol) for flu-like symptoms sev- 
eral days preceding his admission. The patient lived 
alone and emergency medical technicians had been called 
to his home by his mother after she was unable to reach 
him by telephone. 

In the emergency room, the patient was initially leth- 
argic but arousable and communicative. His systolic 
blood pressure was 60mm Hg, pulse 120, respiratory rate 
40 per minute, and his temperature was 36. 1° C. Auscul- 
tation of his lungs revealed bilateral scattered rhonchi. 
Cardiovascular examination showed a regular rate and 
rhythm, tachycardia without murmurs, rubs, or extra 
heart sounds. Examination of the abdomen was un- 
remarkable. Neurological assessment showed a lethargic 
patient but oriented and responsive to questions; he was 
able to move all extremities spontaneously; his pupils 
were dilated but reacted to light. Nasogastric aspiration 
revealed heme-positive fluid. Arterial pH was 6.9. The 
patient was intubated and a Foley catheter was inserted. 

Laboratory data showed a white blood count of 
30,500/ /uL with 72% polys, 19% bands. Hemoglobin was 
17gm/dl, hematocrit 50.8%, mean corpuscular volume 
104.6 fL. The BUN was 9mg/dl, creatinine 4.0mg/dl, 
glucose 85mg/ dl, and serum acetone was negative. The 
prothrombin time was 76.1 seconds, partial thrombo- 
plastin time was 72. 1 seconds. The total bilirubin was 
7.7mg/dl, direct bilirubin 5.3mg/dl, alkaline phospha- 
tase 235 IU / L, lactate dehydrogenase 7,200 IU / L, serum 
aspartate aminotransaminase (AST) 14,200 IU/L, and 
alanine aminotransaminase (ALT) 15,000 IU/L. Serum 
lactic acid was 28 mEq/L, phosphate 12.6mg/dl. Serum 
salicylate concentration was 6.3mg/ dl (therapeutic range: 
3 to 39mg/dl) and serum acetaminophen level was 
13/ug/ml (therapeutic range: 10 to 20;ug/ml). 

The patient was given naloxone, bicarbonate, 50% 
dextrose, and intravenous normal saline infusion. Intra- 
venous dopamine was administered with his systolic 
blood pressure recorded at 70mm Hg; subsequently he 
was given norepinephrine. The patient remained anuric, 

VOLUME 53, NO. 1 


with a systolic blood pressure of 70 to 80mm Hg. A 
loading dose of N-acetylcysteine was given through a 
nasogastric tube for suspected acetaminophen intoxica- 
tion. Seven hours following admission, the patient’s 
blood pressure fell to 50mm Hg with a pulse of 30. 
Attempted cardiopulmonary resuscitation was unsuc- 
cessful and the patient expired. 

The autopsy findings revealed an obese white male 
with an estimated weight of 113 K. The lungs were 
edematous and had a combined weight of 2,350g. The 
brain weighed l,640g and showed cerebral edema with 
cerebellar pressure coning. Multiple sections examined 
microscopically failed to reveal signs of inflammation, 
degeneration, or focal lesions. The liver weighed 2,540g 
and it was not remarkable grossly. A frozen section done 
at the time of autopsy did not reveal any evidence of 
necrosis. Microvesicular vacuolization of the liver cells 
was noted (see Figs. 1 and 2) and an oil-red-0 stain 

Figure 1 

Microvesicular change is noted in the hepatic cells around a central 
vein (arrow). (Original magnification x400.) 

Figure 2 

Microvesicular change around the portal area to the left. A few larger 
fat vacuoles are present, and these were uncommon. (Original magnifi- 
cation x400.) 

Figure 3 

Oil-red-O stain showing extensive fat deposition within hepatocytes, 
staining grey in this reproduction. (Original magnification x200.) 

revealed marked diffuse fine fatty change of the liver cells 
(see Fig. 3). The remainder of the autopsy did not show 
any other significant gross or microscopic abnormalities. 

A postmortem sample of heart blood showed an ace- 
taminophen level of 53mg/L (normal therapeutic range 
40 to 50mg/L). This test was performed in a separate 
laboratory by a different method from the one per- 
formed on the antemortem blood sample. 


The Centers for Disease Control diagnostic criteria for 
RS is defined as: (i) an acute, noninflammatory encepha- 
lopathy documented clinically by an alteration in con- 
sciousness and, if available, a CSF containing less than 
eight leukocytes per 3mm, or by a histological specimen 
of brain demonstrating cerebral edema without peri- 
vascular or meningeal inflammation: (ii) hepatopathy 
documented by either liver biopsy or autopsy considered 
to be diagnostic of Reye’s syndrome or a three-fold or 
greater increase in the levels of the serum AST, ALT, or 
ammonia; and (iii) no other more reasonable explana- 
tion of the cerebral or hepatic abnormalities. 2 The patient 
in the present case fulfilled these diagnostic criteria, ie, 
the progressive encephalopathy and the diagnostic he- 
patic histopathological findings of microvesicular lipid 

While acetaminophen toxicity was initially entertained 
as the differential diagnosis of his altered mental status 
and markedly abnormal liver function tests, this was not 
borne out by the therapeutic acetaminophen levels seen 
in both the ante- and postmortem blood samples ana- 
lyzed by different techniques at different settings. Serum 
salicylate levels in RS are invariably reported to be 
within the therapeutic range. 3 The pathological changes 
noted were consistent with RS. Acetaminophen hepato- 
toxicity is manifested by centrilobular necrosis. 4 The 
difficulty in initial diagnosis was additionally compli- 
cated by markedly elevated AST, ALT, and bilirubin 
levels: 14,200 IU/L, 15,000 IU/L, and 7.7 mg/dl respec- 



tively. In RS, the ALT and AST levels are usually ele- 
vated no more than three to 30 times normal and the 
total bilirubin rarely exceeds 1 mg/dl. 1 Acetaminophen 
hepatotoxicity usually causes profoundly elevated amino- 
transaminase levels as high as 30,000 1/1/ L. 5 

Serum concentrations greater than 50 times normal 
are associated with fatal cases of acetaminophen toxi- 
city, 4 which usually occurs following ingestion of 200 to 
250mg/ kg body weight, 6 or about 1 5g in a 70kg person. 4 ’ 5 

Reye’s syndrome has been epidemiologically related 
to salicylate use during a viral illness. 7 The amount of 
salicylate ingestion is not correlated with propensity for 
development of RS, nor with the level of encephalopathy 
on presentation. 8 The syndrome has not been reported to 
be secondary to salicylate intoxication. While the epi- 
demiological pattern of prior salicylate use now appears 
well established by at least five studies, 9 there are anec- 
dotal reports in the literature of acetaminophen-induced 
Reye’s syndrome. 3 DeVivo points out that hepatic necro- 
sis is an infrequent finding in RS, and where present, 
occurs in periportal areas. Acetaminophen toxicity char- 
acteristically causes centrilobular necrosis. 5 Micro vesi- 
cular hepatocyte steatosis seen in RS has similarly been 
noted in cases of salicylate intoxication. 1 

In a matched case-control study, Halpin found a prior 
history of aspirin use in 97% of patients with Reye’s 
syndrome. Sixteen percent of patients with RS in his 
study had taken acetaminophen prior to developing 
symptoms of RS, while 33% of the matched control 
group which did not develop RS had taken acetamino- 
phen. Eight percent of patients with RS had a prior 
history of recent phenothiazine exposure, which was not 
statistically different from the 4% usage reported in the 
control group. 3 The use of the phenothiazine Thorazine 
by the patient in this study would therefore not contrib- 
ute to the observed histological findings. 

Microvesicular steatosis is an uncommon pathologi- 
cal finding, but has been clinically reported to occur in 
fatty liver of pregnancy, cholesterol ester storage disease, 
carnitine deficiency, congenital defects of urea cycle 
enzymes, tetracycline toxicity, valproate toxicity, Jamai- 
can vomiting sickness, 15 Sierra Nevada de Santa Marta 
hepatitis, 16 and in Reye’s syndrome. The historical and 
clinical findings in this patient are most consistent with 
Reye’s syndrome as the etiology of the hepatic histo- 

In addition to an unknown quantity of aspirin inges- 
tion in our patient, he was also taking bismuth subsalicy- 
late for gastrointestinal symptoms. Viral gastroenteritis 
has been reported as the prodromal illness in 5% to 15% 
of cases of RS. 1 A United States Public Health Service 
study of 30 cases in 1984 reported two patients who had 
bismuth subsalicylate exposure prior to developing 
symptoms of RS, including one case for whom this 
represented the only salicylate exposure. 10 

Between 1973 and 1986, there have been 3,653 cases of 
RS reported to the CDC from the National Reye Syn- 
drome Surveillance System, with a case mortality rate of 
26 to 42%. 2 ’ 17 Since 1973, there have been only 24 

reported cases in the literature of patients older than 
18. ii, I 4 , is, i9 There appears to be no clinical, epidemiolog- 
ical, or pathological differentiation in RS diagnosed in 
children versus adults. Children under ten years of age 
have the greatest incidence of RS. Since 1980, there has 
been a 55% decrease in occurrence among the less than 
ten-year-old population, and a 33% decline in the ten to 
19-year-old population. 2 This may reflect decreased usage 
of salicylates for viral illnesses in the United States. In 
summary, Reye’s syndrome is generally considered a 
childhood disease. We described our experience with one 
adult patient in whom the diagnosis of RS was con- 
firmed. The occurrence of RS in adults should be noted 
and prompt recognition of the characteristic presenta- 
tion should be extended to the emergency room setting. 


1. Heubi JE, Partin JC, Partin JS, and Schubert WK: Reye’s syn- 
drome: Current concepts. Hepatology 1987;7:155-64. 

2. Barrett MJ, Hurwitz ES, Schonberger LB, and Rogers MF: 
Changing epidemiology of Reye’s syndrome in the United States. 
Pediatrics 1986;77:598-602. 

3. De Vivo DC: Reye’s syndrome. Neurol Clin 1985;3:95-115. 

4. Zimmerman HJ: Effects of aspirin and acetominophen on the 
liver. Arch Int Med 1981;141:333-41. 

5. Seeff LB, Ceccherini BA, Zimmerman HJ, et al: Acetominophen 
hepatoxicity in alcoholics. Ann Int Med 1986; 104:399^404. 

6. Flower RJ, Moncada S, Vane JR: Analgesic-antipyretics and 
anti-inflammatory agents. In: Gilman AG, Goodman LS and 
Gilman A., eds. The Pharmacological Basis of Therapeutics. 6th 
ed. New York; Macmillan Publishing Co.; 1980:703. 

7. Kolata G: Study of Reye’s-aspirin link raises concern. Science 

8. Halpin TJ, Holtzhauer FJ, Cambell RJ, et al: Reye’s syndrome 
and medication use. JAMA 1982;248:687-691. 

9. Hurwitz ES, Barrett MJ, Bregman D, et al: Public health service 
study on Reye’s syndrome and medication. JAMA 1987; 

10. Barrett MJ: Association of Reye’s syndrome with use of Pepto- 
Bismol (TM) (letter). Ped Inf Dis 1986;5:610-1 1. 

1 1. Varma RR, Reidel DR, Komorowski RA, et al: Reye’s syndrome 
in nonpediatric age groups. JAMA 1979;242:1373-1375. 

12. Kirkpatrick DB, Ottoson C, Bateman LL: Reye’s syndrome in an 
adult patient. West J Med 1986;144:223-25. 

13. Peters LJ, Weiner GJ, Gilliam J, et al: Reye’s syndrome in adults. 
Arch Int Med 1986;146:2401-03. 

14. Meythaler JM and Varma RR: Reye’s syndrome in adults Arch 
Int Med 1987;147:6M. 

1 5. Colletti RB, Trainer TD, Krawisz BR: Reversible valproate fulmi- 
nant hepatic failure. J Pediatr Gastroenterol Nutr 1986;5:990-4. 

16. Buitrago B, Popper H, Hadler SC, et al: Specific histological 
features of Santa Marta hepatitis: severe form of hepatitis-virus 
infection in Northern South America. Hepatology 1986;6: 

17. CDC: Reye’s syndrome surveillance. MMWR 1987;36:689-91. 

18. Brown RE and Madge GE: Hepatic degeneration and dysfunction 
in Reye’s syndrome. Am J. Dig. Dis. (New ser.) 1971; 16: 1 1 12-22. 

19. Nesbitt JAA and Minuk GY: Adult Reye’s syndrome. Ann Emer 
Med 1988;17:155-58. 

VOLUME 53, NO. 1 


Ectopic ACTH and Adrenal Myelolipoma 


ABSTRACT— We describe a case of adrenal myelo- 
lipoma that occured in a 66-year-old male with an 
ACTH producing oat cell lung carcinoma. To our knowl- 
edge, this is the first case in which myelolipoma has 
occurred in association with ectopic ACTH-induced 
Cushing’s syndrome. The literature is reviewed and the 
pathogenesis of myelolipoma is discussed. 

A DRENAL myelolipoma, an uncommon benign 
tumor containing hematopoietic and adipose tissue, 
has been found in 0.08-0.2% of autopsies 1 and in a 
smaller percentage of surgical biopsy specimens. 2 " 4 Four 
cases have been reported in the setting of endogenous 
Cushing’s syndrome. 4 ' 7 The cause of elevated glucocorti- 
coids in these reported cases was pituitary adenoma, 
adrenal adenoma, or idiopathic adrenal hyperplasia. We 
report a case in which adrenal myelolipoma was found in 
association with bilateral adrenal hyperplasia due to an 
ectopic source of ACTH. 

Case Report 

The patient, a 66-year old white male, was admitted to 
Danbury Hospital on 5 May 1988 with a one-week 
history of dyspnea and nonproductive cough. His symp- 
toms included a progressive weakness, anorexia, and a 
one to two pound weight loss. His past medical history 
included long-standing hypertension, and his current 
medication was spironolactone lOOmg four times daily. 
He had a 25 year history of cigar smoking. During a 
recent outpatient evaluation for worsening hyperten- 
sion, a chest film (29 March 1988) was normal. Two 
weeks prior to admission, his serum potassium level was 
found to be 1.8 mEq/1, associated with a decreased 
serum renin level (0.5 ng/ml/h). An abdominal compu- 
terized tomographic (CT) scan at that time showed a well 
circumscribed 5 cm mass arising from the left adrenal 
gland (Figure 1). 

STEVEN C. SIEBER, M.D., Pathology Resident, Department of 
Laboratory Medicine, Danbury Hospital. NELSON A. GELFMAN, 
M.D., Attending Pathologist, Department of Laboratory Medicine, 
Danbury Hospital; Assistant Clinical Professor of Pathology, Yale 
University School of Medicine. RONALD DANDURAND, M.D., 
Medical Resident, Department of Medicine, Danbury Hospital. 
FRANK BRAZA, M.D., Attending Pathologist, Department of La- 
boratory Medicine, Danbury Hospital, Danbury, CT. 

Physical examination on admission showed a blood 
pressure of 170/80 and pulse of 110 supine. There were 
diminished breath sounds and rales at the left lung base 
and marked pitting ankle edema. No abdominal mass 
was palpated. A chest film showed a dense left lower- 
lobe infiltrate, patchy nodular right lung infiltrates, and a 
layering left pleural effusion. 

His leukocyte count was 2 1 ,500 /ri, with a left shift. The 
hemoglobin level was 16.2 g/ dL; hematocrit 49.0%; and 
platelet count 99,000. The serum sodium was 1 39 mEq/ 1 ; 
potassium 2.1 mEq/1; chloride 91 mEq/1; bicarbonate 
39 mEq/ 1, blood urea nitrogen 29 mg/dl; creatinine 1.2 
mg/dl; and glucose 155 mg/ dl. An arterial blood gas on 
room air showed pH 7.59, pC0 2 38 mmHg, and p0 2 33 

On admission, intravenous fluids and antibiotics were 
administered and on the following day, open lung biop- 
sies of the right upper and lower lobes were obtained. 
Postoperatively the patient remained hypoxemic and 
ventilator-dependent and developed a low-grade fever. 
An afternoon cortisol drawn on admission was reported 
to be 139 Mg/dl and a morning cortisol was 116 Mg/dl 
(reference range 5-20Mg/dl). On the second postopera- 
tive day the biopsy results were reported as showing 
cytomegalovirus pneumonitis, invasive aspergillosis, and 
Pneumocystis carinii pneumonitis without evidence of 
tumor. 9 Amphotericin B was given but despite aggressive 
management, the patient developed septic shock with 
Disseminated Intravascular Coagulation (D.I.C.) and 
expired on the sixth hospital day. An elevated ACTH 
level of 430 pg/ml, (reference range 0-70 pg/ml), drawn 
two weeks prior to admission, was returned postmortem. 
Antibody to HIV was undetectable in the serum. Multi- 
ple blood cultures remained negative. 


Tissue was fixed in 10% buffered formaldehyde, em- 
bedded in paraffin, and stained with hematoxylin-eosin. 
Selected sections were also stained with silver-meth- 
enamine. Immunohistochemical studies were performed 
on selected deparaffinized sections using the avidin- 
biotin complex method. 9 Primary antisera against ACTH 
(BioGenex, Dublin, CA) was used. Antigenically 

VOLUME 53, NO. 1 


well characterized tissues served as the positive control. 
The primary antibody was deleted for the negative 

Cortisol was measured in frozen EDTA-treated plasma 
by radioimmunoassay. ACTH was measured by radio- 
immunoassay in fasting plasma, immediately frozen after 
collection and assayed within 30 days of collection. 

Figure 2 

Left: Coronal section of the left lung showing an infiltrating tumor 
arising in the region of the left lower lobe bronchus and also involving 
the neighboring peribronchial lymph nodes. In the adjacent lung 
parenchyma, several Aspergillus abcesses are visible. Right: Section of 
the left lung tumor showing oat-cell carcinoma (hematoxylin-eosin, 

to be the oat-cell subtype of small-cell carcinoma (Figure 
2, right). Metastatic tumor was present in hilar and 
mediastinal lymph nodes and within the liver. Sections of 
the tumor failed to stain for immunoreactive ACTH. 

Grossly, both lungs also showed multiple cystic and 
miliary lesions. Microscopically, these areas showed acute 
inflammation, necrosis, abundant Aspergillus species, 


Figure 1 

Computed tomographic scan of the patient showing a well-circum- 
scribed mixed-density mass arising from the left adrenal gland. 

Pathologic Findings 

At autopsy, a 5.5 cm firm, tan-gray infiltrating tumor 
was discovered in the region of the left lower lobe bron- 
chus (Figure 2, left). Microscopically, the tumor proved 


i - 


Pneumocystis carinii, and changes consistent with cyto- 
megalovirus infection. 8 Aspergillus microabscesses were 
seen in the brain, heart, thyroid, pancreas, and kidneys. 

The pituitary gland showed no significant histopatho- 
logical changes. Stains for ACTH showed minimal focal 
positivity. This was in contrast to control tissue from 
pituitaries of non-Cushingoid patients and from one 
individual with corticotropin releasing factor-producing 
tumor, which were strongly positive by this method. 

The adrenal glands showed bilateral cortical hyper- 
plasia with a hypertrophic compact cell histology. A 
large spherical tan-brown mass measuring 5.5 cm in 
diameter was attached to the lateral limb of the hyper- 
plastic left adrenal gland (Figure 3). Sections of this mass 

Figure 3 

Sagittal section of left adrenal gland showing a well-circumscribed 
mass arising from the lateral limb. The uninvolved adrenal cortex 
appears hyperplastic. 

showed a benign proliferation of adipocytes and hema- 
topoietic elements diagnostic of myelolipoma (Figure 4). 
These elements were admixed with cords of hypertrophic 

Figure 4 

Section of the left adrenal mass showing a benign proliferation of 
adipocytes and hematopoietic elements, admixed with nests of hyper- 
trophic compact adrenal cortical cells (hematoxylin-eosin, X20). 

adrenocortical cells. The tumor failed to stain for immu- 
noreactive ACTH. 



The marked elevation of plasma ACTH (430 ug/1) in 
our patient in conjunction with the bilateral adrenal 
hyperplasia and decreased pituitary staining for ACTH 
point to an ectopic source of ACTH. The lipid-depleted, 
uniformly hypertrophied, and hyperplastic compact cell 
histology of both adrenal cortices is virtually pathogno- 
monic of ectopic ACTH syndrome. 10 ’ 11 Also consistent 
with this entity is the patient’s presentation with hypoka- 
lemic metabolic alkalosis in the absence of the classic 
signs of Cushing’s syndrome. 

The oat-cell carcinoma of the lung is the probable 
ectopic source of ACTH in our patient. This tumor is 
responsible for about 60% of cases of ectopic ACTH 
syndrome. 12-16 The absence of other potential sources of 
ACTH in our patient, including islet-cell tumor of the 
pancreas, thymoma, carcinoid, and medullary carcinoma 
of the thyroid as well as the absence of ACTH in the 
myelolipoma also makes an oat-cell source more likely. 

The oat-cell tumor repeatedly failed to stain for ACTH 
by immunohistochemical techniques. This finding is not 
unexpected. Coates, et al, recently studied 18 cases of 
Cushing’s syndrome caused by an ectopic source of 
ACTH. 18 The cases were divided into two groups: one 
group of 12 with less aggressive or benign tumors, and a 
group of six with highly malignant tumors. Of the first 
group of 12 neoplasms, ten stained positively for ACTH, 
pro-opiomelanocortin (POMC), or both by immuno- 
cytochemistry. Conversely, none of the six highly malig- 
nant tumors, including three small-cell lung carcinomas 
(plasma ACTH 389-1502 mg/1), stained positively for 
ACTH or POMC. The authors concluded that a feature 
of these highly malignant sources of ACTH is high and 
rapid secretion of peptide hormones, resulting in amounts 
that are too small to be shown by conventional immuno- 
histochemical techniques. The highly malignant tumor 
in our patient was probably behaving in such a manner. 

Coexisting adrenal myelolipoma and ectopic ACTH 
syndrome have not been previously reported. The 
pathogenosis of adrenal myelolipoma in our case is not 
clear. Although extreme elevation of the serum cortisol is 
clearly documented, the nature of the ectopic source of 
ACTH, ie, a small highly malignant oat-cell carcinoma, 
is not consistent with the large size of the myelolipoma. 
The oat-cell carcinoma probably developed over the 
course of six months or less. A chest film taken six weeks 
prior to admission was read as unchanged from normal 
films taken in recent years. The 5.5cm benign myeloli- 
poma almost certainly had been present for longer than 
six months, before the presence of the elevated ACTH 
and resulting hypercortisolism. Therefore, it is difficult 
to implicate a hypercortisol state as a causative factor in 
this case of adrenal myelolipoma. The simultaneous 
occurrence of ectopic ACTH and adrenal myelolipoma 
in this patient is probably coincidental. 

Myelolipoma is a benign adrenal neoplasm consisting 

of lipoid and hematopoietic elements in varying propor- 
tions. This entity is uncommon, usually found as an 
incidental finding at autopsy. Less than 200 cases have 
been reported in the literature. It is widely held that the 
origin of both lipoid and myeloid cells within the myeloli- 
poma is the precursor reticulum cell. 18 The nature of the 
stimulus required to cause this differentiation is not 

Adrenal myelolipomas have often been found in 
patients with chronic and stressful conditions, such as 
major burns 19 and malignancy. 3 These clinical states are 
associated with excess cortisol production as an adapta- 
tion to stress. Selye and Stone were able to produce 
adrenal myelolipomas in rats by injection of crude 
ACTH-containing anterior pituitary extracts and testos- 
terone. 20 These observations suggest that stimulation 
with ACTH or cortisol may be involved in the patho- 
genesis of adrenal myelolipoma. 

In the past decade, four cases of adrenal myelolipoma 
occurring in association with Cushing’s syndrome have 
been reported. Causes of hypercortisolism in these 
patients were pituitary adenoma, 4 ’ 7 adrenal adenoma, 6 
and autonomous bilateral adrenal hyperplasia. 5 The 
authors postulate a role for glucocorticoids in the patho- 
genesis of adrenal myelolipoma. 

Of interest is the radiologic appearance of the left 
adrenal myelolipoma by CT scan (Fig 1). Although 
radiologic signs are often equivocal, myelolipomas gen- 
erally have fat density values on CT scans and appear 
well circumscribed. 5 Our case satisfied these criteria. 
Also of interest is the failure of the CT scan to detect the 
bilateral adrenal hyperplasia in this case. Adrenal hyper- 
plasia is difficult to detect with CT because the degree of 
cortical thickening is often only a few millimeters above 
normal. However, when marked bilateral adrenal enlarge- 
ment is demonstrated by CT, the most likely cause is an 
ectopic ACTH-producing neoplasm, regardless of the 
results of high dose dexamethasone suppression. 22 


1. Olsson CA, Krance RJ, Klugo RC, Selikowitz SM: Adrenal mye- 
lolipoma. Surgery 1973;73:665-70. 

2. Parsons L, Thompson JE: Symptomatic myelolipoma of the 
adrenal gland. New Engl J Med 1959;260:12-15. 

3. Gee WF, Chikos PM, Greaves JP: Adrenal myelolipoma. Urology 

4. Bennett BD, McKenna TJ, Hough AJ, et al: Adrenal myelolipoma 
associated with Cushing’s disease. Am J Clin Path 1980;73:443-46. 

5. Kanj HA, Norouha J, D’Aquillo AF, et al: Bilateral adrenal 
myelolipomas with Cushing’s syndrome. JAMA 1988;259: 

6. Nyberg M, Sesloft L: Combined adrenal myelolipoma and ade- 
noma associated with Cushing’s syndrome Am J Clin Path 1986;86: 

7. Maschler I, Rosenmann E, Ehrenfeld EN: Ectopic functioning 
adrenocortico-myelolipoma in longstanding Nelson’s syndrome. 
Clin Endocrinol (Oxf) 1976;10:493-97. 

8. Dandurand R, Sieber S, Gelfman N, Braza F: unpublished results, 

VOLUME 53, NO. 1 


9. Hsu SM, Raine L, Fanger H: The use of antiavidin antibody and 
avidin-biotin peroxidase complex in immunoperoxidase technics. 
Am J Clin Pathol 1981;75:816-21. 

10. Gelfman NA: Morphologic changes of adrenal cortex in disease. 
Yale J Biol Med 1964;37:31-54. 

1 1 . Symington T: The Adrenal Cortex, in Bloodwart JMB (ed): Endo- 
crine Pathology. Baltimore, Williams and Williams, 1982, pp. 419-62. 

12. Ibid, pp 223-28. 

13. Gelfman NA: Bronchogenic carcinoma with Cushing’s syndrome. 
Am Rev Resp Dis 1961;83:555-62. 

14. Azzopardi JG, Williams ED: Pathology of non-endocrine tumors 
associated with Cushing’s syndrome. Cancer 1968;22:274-86. 

15. Baylin SB: Ectopic production of hormones and other proteins by 

tumors. Hosp Prac 1969;36:117-26. 

16. Imura H, Matsukura S, et al: Studies on ectopic ACTH producing 
tumors. Cancer 1975;35:1430-37. 

17. Coates PJ, Doniach I, Howlett TA, et al: Immunocytochemical 
study of 18 tumors causing ectopic Cushing’s syndrome. J Clin 
Path 1986;39:955-60. 

18. Plant A: Myelolipoma in the adrenal cortex. Am J Path 1958; 

1 9. Delarne J, Monsaingeon A: Metaplaisies myeloides dans la cortico 
surrenale des brules. C R Soc Biol (Paris) 1950; 144:777-78. 

20. Selye H, Stone H: Hormonally induced transformation of adrenal 
into myeloid tissue. Am J Path 1950; 26:21 1-33. 

21. Pojunas KW, Daniels DL, et al: Pituitary and adrenal CT of 
Cushing’s syndrome. AJR 1986; 146:1235-38. 

50 Years Ago 

From the Journal of the Connecticut State Medical Society 

January 1939 


“Behind the Syphilis Campaign,” a pamphlet com- 
piled by Dr. Philip S. Broughton with the aid of members 
of the Division of Venereal Diseases of the United States 
Public Health Service, has just been issued by the Public 
Affairs Committee of New York City. It carries a mes- 
sage to the lay public about syphilis and within its covers 
the author briefly describes the symptoms of syphilis and 
the methods of spread. 

Each year 518,000’ cases of newly infected patients 
report to doctors and clinics for treatment and, in addi- 
tion, 598,000 advanced cases come to doctors for the first 
time. The advanced cases are important because they 
had a year or more during which they were uncontrolled 
and able to spread the disease. Nearly half of these 
infections are innocently acquired: in marriage, at birth, 
through chance contacts, or, rarely, through soiled tow- 
els, drinking cups and similar articles. The author points 
out that were the syphilis rate in the United States as low 
as it is in Denmark, we would have 26,000 cases instead 
of more than 1,000,000. 

The cost of this disease is stupendous and is summed 
up in a slogan of the United States Public Health Service: 
“The cheapest thing America can do with its million 
cases of syphilis is to cure them.” 

1 . Compared with about 40,000 in 1988 (from MMWR, 16 Decem- 
ber 1988. -Editor). See also this issue, pp. 35-6. 

The modern approach in the current campaign to 
eradicate syphilis has, as its keynote, the appeal to confi- 
dence and not to fear, because a frightened patient is 
likely to take the wrong course and a quack may quiet his 
fears more quickly than an honest physician. Specific- 
ally, the present campaign directs itself to the creation of 
adequate facilities for diagnosis and treatment, routine 
blood tests and the follow-up of cases. 

The author stresses the fact that syphilis can be cured 
and that early treatment shows the best results. Even in 
late stages, however, treatment markedly diminishes the 
frequency of brain and nervous system involvement. In 
an untreated syphilitic mother there are five chances out 
of six that the baby will be born dead or infected with 
syphilis, whereas, in the cases of the treated mother, the 
baby will be healthy ten times out of eleven. 

The United States Public Health Service has formu- 
lated a policy for industry in its relation to syphilis. In 
brief this policy encourages the following: (1) Routine 
blood tests for job seekers with employment if syphilitic, 
providing treatment is accepted. (2) Blood tests as part 
of regular physical examination of employees. (3) Edu- 
cational program which will give employees an under- 
standing of the problem. (4) Treatment of employees by 
industrial medical services, unless competent treatment 
can be arranged through private physicians. 

— Editorial by Creighton Barker, M.D. 



Adenocarcinoma of the Cervix Arising in Pregnancy 


A CASE of invasive adenocarcinoma of the cervix in 
pregnancy is reported. A review of the literature 
reveals that this neoplasm is infrequently encountered 
during pregnancy. Cervical carcinoma is the most fre- 
quently occurring malignancy in pregnancy. The fre- 
quency of diagnosis of cervical carcinoma during preg- 
nancy is increasing as initial prenatal obstetric man- 
agement involves routine Papanicolaou smears. A brief 
review of the literature will be presented. 


Cervical carcinoma is the most frequently occurring 
malignancy in pregnancy, followed by breast car- 
cinoma. 1 The literature states that primary adenocarci- 
noma of the cervix comprises approximately 10% to 1 5% 
of all new cases. 2 However, reports of cervical adenocar- 
cinoma associated with pregnancy are rarely encoun- 
tered. Primary adenocarcinoma of the cervix and endo- 
cervix is cytologically evasive, variable in its histologic 
appearance, and confusing from a therapeutic standpoint. 

There is a delay in the early diagnosis of adenocarci- 
noma of the cervix. Cervical cytology has not been as 
helpful in the early detection of adenocarcinoma of the 
cervix as it has been for squamous cell carcinoma. 2 ’ 3 

The histologic diversity of this lesion may be responsi- 
ble for the more advanced stage at the time of the diagno- 
sis. This is one of the factors that has been associated 
with a poorer prognosis for this neoplasm when com- 
pared to squamous cell carcinomas. 2 ’ 3 Other factors 
affecting prognosis are related to lower uterine segment 
involvement, local growth, and the frequency of distant 

The possibility of a hormonally mediated etiology of 
adenocarcinoma of the cervix has been suggested. 

Peters et al hypothesize an association between cervi- 
cal adenocarcinoma and oral contraceptive use in early 
adolescence, but state that further studies are needed to 
verify this relationship. 4 

Hacker et al reviewed 579,795 pregnancies for invasive 

MARIA P. LENAZ, M.S., M.D., Associate Physician, Department of 
Obstetrics and Gynecology, Concord Hospital, Concord, New Hamp- 
shire. RICHARD Z. BELCH, M.D., Ph.D., Gynecologic Oncologist, 
Department of Obstetrics and Gynecology, Dartmouth-Hitchcock 
Medical Center, Hanover, New Hampshire. 

disease and found an incidence of one in 2,205. The 
majority presented with abnormal bleeding, whereas a 
smaller percentage were asymptomatic. Most patients 
present with a gross lesion, requiring a biopsy for diagno- 
sis. There is a reported 8% to 40% false negative rate 
when random biopsies are used. 6 ’ 7 

Invasive carcinoma of the cervix in pregnancy is asso- 
ciated with an average age of 33 years. This age is signifi- 
cantly lower than the average age reported for nonpreg- 
nant women with invasive cervical carcinoma. The major- 
ity of patients were grand multiparas. 8 ’ 9 ’ 10 
Case Report 

M.H. was a 29-year-old female, married, gravida 1 
para 0, with an uncomplicated pregnancy until 37 weeks’ 
gestation when a polypoid mass was discovered on the 
anterior lip of her cervix. A punch biopsy measuring 
approximately 1.5 cm x 1.0 cm x 0.3 cm was obtained. 
The histologic study revealed only a blood clot contain- 
ing acute inflammatory, squamous, and glandular cells. 

The patient had been otherwise in good general health. 
She had begun to menstruate at 13 years, with regular 
cycles every 28 days, lasting 3 to 4 days. She had annual 
gynecological examinations with normal Papanicolaou 
smears. Her last smear, at her initial prenatal visit, was 
Class I. She had a ten-year history of oral contraceptive 
use without any difficulties. She denied using estrogen, 
or in utero diethylstilbesterol exposure. Her past medical 
history and surgical history were unremarkable. She has 
a known sensitivity to penicillin. She admitted to smok- 
ing one-half pack of cigarettes daily for two years, but 
had stopped one year before this pregnancy. She had a 
negative family history for carcinoma. 

She had an episode of vaginal spotting after a pelvic 
examination at 38 weeks, which resolved spontaneously. 
She had a reactive nonstress test, and no further bleeding 
episodes. An earlier ultrasound examination had revealed 
an anterior right lateral and fundal placenta; a single 
intrauterine pregnancy, in a vertex presentation, with a 
confirmed age of gestation, normal fluid volume, fetal 
movement, and other parameters observed, and no evi- 
dence of placenta praevia. 

The patient was admitted in active labor with intact 
membranes at 41 weeks age of gestation. She underwent 
a primary cesarean section for fetal distress, at which 

VOLUME 53, NO. 1 


time a polyp was excised from the right lower cervical 
segment and sent for pathological examination. She was 
delivered of a living male infant, weighing 7 lb. 12 oz, 
with Apgar scores of 9 1 / 10 5 , from a left occiput posterior 
position. A nuchal cord x 2 was noted, as well as 
meconium-tinged fluid. 

She was empirically given gentamicin intravenously 
for prophylaxis. Her postoperative course was notable 
for an endomyometritis for which intravenous clinda- 
mycin was added to the gentamicin therapy. After being 
afebrile during 48 hours of intravenous therapy she 
began oral therapy, and was discharged home on her 
sixth postoperative day. 

Pathological studies revealed an invasive moderately 
well-differentiated adenocarcinoma of the cervix. Occa- 
sional solid components, mucin production, acute inflam- 
mation, and lymphatic vessel invasion were observed. 
The placenta was normal. 

She was referred for treatment of a stage 1 B adenocar- 
cinoma of the cervix. 

The preoperative laboratory work was within normal 
limits, as was an intravenous pyelogram. 

She underwent a cystoscopy, proctoscopy, and an 
examination under anesthesia. 

Cystoscopic and proctoscopic examinations were en- 
tirely normal. A bimanual and rectovaginal examination 
revealed no abnormalties. The uterosacral ligaments and 
parametria were not thickened or irregular. 

A radical hysterectomy, bilateral salpingectomy, and 
paraortic, common iliac, and pelvic lymphadenectomy 
were performed. At operation there was no evidence of 
gross adenopathy; the frozen section was negative for 
tumor; examination of the uterus revealed tumor in the 

The final pathologic diagnosis was consistent with 
reactive serosal and peritoneal inflammation in the para- 
metrium and peritoneal cavity, with no evidence of 
malignancy. The pelvic lymph nodes, paraortic, obtura- 
tor, and hypogastric nodes showed no tumor. 

Her postoperative course was notable only for pares- 
thesias of the digits of her left hand. A neurologist felt 
that the paresthesias were the result of irritation by the 
radial arterial line; they resolved without any residual 
deficit. She was discharged on the seventh postoperative 
day in good condition, and has required no further 


Although the coincidence of cervical adenocarcinoma 
and pregnancy is known, 2 ’ 8 ’ 11 this case illustrates an 
unusual presentation and coexistence of this invasive 
adenocarcinoma of the cervix and pregnancy. 

As glandular involvement tends to be focal, a biopsy 
specimen may prove to be unsatisfactory when only 
surface involvement is sampled. 12 The fact that adeno- 
carcinoma can metastasize as whole glands may cause 
difficulty in differentiating between adjacent intraepithe- 
lial changes and invasive disease. 

In view of the nature of the lesion and the site, it is 

understandable that routine cytological smears may not 
necessarily include cells revealing a malignancy. 13 ’ 14 
It is known that cervical tissues are responsive to 
estrogens, and it appears that cervical adenocarcinoma is 
more responsive than its squamous counterpart. 4 ’ 15 It 
has been proposed that the use of oral contraceptive pills 
may be linked to cervical cancer or its precursors. 4 ’ 16 
The treatment for invasive disease, radical hysterec- 
tomy versus radiation therapy, is based on the stage of 
the cancer and is the same as that used in the nonpreg- 
nant state. The survival rate seems to be unchanged from 
that of the nonpregnant patient. 7 ’ 9 ’ 17 In a report of 49 
cases of stage IB cervical carcinoma in pregnancy by 
Nisker and Shubat, 18 the five-year survival rates and 
complications are compared for both modes of therapy. 
According to their data, the radical hysterectomy and 
pelvic lymphadenectomy, with subsequent radiotherapy 
for tumor positive nodes, appears to be the preferred 
form of treatment when the diagnosis is established in 
mid- or late trimester of pregnancy. 18 


1. Nieminsen N, and Remes N: Malignancy during pregnancy. Acta 
Obstet Gynecol Scand 1970;49:315-20. 

2. Matey D, and Gallup D: Adenocarcinoma in situ of the cervix 
during pregnancy. Obstet Gynecol 1979;54:663-66. 

3. Hurt WG, Silversberg SG, and Frable WJ: Adenocarcinoma of 
the cervix: Histopathologic and clinical features. Am J Obstet 
Gynecol 1977;129:304-15. 

4. Peters RK, Chao A, Mack T, Thomas D, Bernstein L, and 
Henderson, B: Increased frequency of adenocarcinoma of the 
uterine cervix in young women in Los Angeles County. J N C I 

5. Cove H: The Arias-Stella reaction occurring in the endocervix in 
pregnancy. Am J Surg Pathol 1979;3:567-68. 

6. Hacker NF, Berek J S, Lagasse LD, et al: Carcinoma of the cervix 
associated with pregnancy. Obstet Gynecol 1982;59:735-46. 

7. Roberts JA: Management of gynecologic tumors during preg- 
nancy. Clinics in Perinatology 1983;10:369-82. 

8. Lutz MH, Underwood PB, Rozier JC, et al: Genital malignancy in 
pregnancy. Am J Obstet Gynecol 1977;129:536-42. 

9. Thompson TD, et al: The surgical management of invasive cancer 
of the cervix in pregnancy. Am J Obstet Gynecol 1975;121:853-63. 

10. Creasman WT, Rutledge FN, and Fletcher GH: Carcinoma of the 
cervix associated with pregnancy. Obstet Gynecol 1970;36:495-500. 

1 1. Edinger DD and Louis FJ: Adenocarcinoma-in-situ of the cervix 
with co-existent intrauterine pregnancy: Report of a case and 
review of the literature. Clin Exp Obst Gyn 1982;9:223-25. 

12. Drew, NC: Adenocarcinoma-in-situ of the cervix uteri associated 
with cervical intraepithelial neoplasia in pregnancy. Case report. 
Brit J of Obstet and Gynecol 1984;91:498-502. 

13. Boon ME, Baak JPA, Kurver PJH, Overdiep SH, and Verdont 
EW: Adenocarcinoma-in-situ of the cervix: An undiagnosed lesion. 
Cancer 1981;48:768-73. 

14. Bousefield L, Pacey F, Young Q, Krumins I, and Osborn R: 
Expanded cytological criteria for the diagnosis of adenocar- 
cinoma-in-situ of the cervix and related lesions. Acta Cvtol 1980;24: 

15. Mingeot R and Fievez CL: Endocervical changes with the use of 
synthetic steroids. Obstet Gynecol 1974;44:53-9. 

16. Vessey MP, McPherson K, Laeless M, et al: Neoplasia of the 
cervix uteri and contraception: A possible adverse effect of the pill. 
Lancet 1983;2:930-34. 

17. Underwood PB, Wilson WC, Kreutner A, Miller MC,and Murphy 
E: Radical hysterectomy: a critical review of the twenty-two years’ 
experience. Am J Obstet Gynecol 1979;134:889-98. 

18. Nisker JA and Shubat M: Stage IB cervical carcinoma and preg- 
nancy: Report of 49 cases. Am J Obstet Gynecol 1983;145:203-6. 




Important Advances in Clinical Medicine 


The Scientific Board of the California Medical Association presents the following inventory of items of progress 
in pediatrics. Each item, in the judgment of a panel of knowledgeable physicians, has recently become 
reasonably firmly established, both as to scientific fact and important clinical significance. The items are 
presented in simple epitome and an authoritative reference, both to the item itself and to the subject as a whole, 
is generally given for those who may be unfamiliar with a particular item. The purpose is to assist busy 
practitioners, students, research workers, or scholars to stay abreast of these items of progress in pediatrics 
that have recently achieved a substantial degree of authoritative acceptance, whether in their own field of 
special interest or another. 

The items of progress listed below were selected by the Advisory Panel to the Section on Pediatrics of the 
California Medical Association and the summaries were prepared under its direction. 

Ribavirin and Respiratory Syncytial 
Virus Infections 

R ESPIRATORY Syncytial Virus (RSV) is the most 
frequent cause of hospital admissions of infants 
with respiratory tract disease. In previously healthy in- 
fants, the RSV infection subsides in three to seven days, 
and most infants recover without sequelae; some will 
have reactive airway disease with subsequent respiratory 
tract infections. Substantial morbidity and, infrequently, 
death may occur among infants with preexisting severe 
pulmonary or cardiac disease. Most severely affected 
infants have signs and symptoms of bronchiolitis or 
acute pneumonitis, or both, and clinically significant 
hypoxemia develops due to bronchiolar spasm or al- 
veolar-capillary block, or both. A significant proportion 
of the sickest infants require ventilatory support. In those 
infants with severe bronchopulmonary dysplasia, severe 
cyanotic heart disease with increased pulmonary blood 
flow, and cellular immunodeficiency syndromes, the 
outcome may be uncertain. 

RSV infection is generally limited to the respiratory 
tract epithelium; the pathogenesis of the disease proba- 
bly is an extensive cellular pathologic disorder and acute 
host-medicated responses, including immunoglobulin 
(Ig) E-mediated activity. Ribavirin aerosol therapy, 
developed over the past decade, appears to ameliorate or 
diminish these pathologic events. 

Ribavirin (Virazole) is a nucleoside analogue that is 
activated in host tissues to its phosporylated form; anti- 

Reprinted from The Western Journal of Medicine, October, 1988. 

viral activity results in the inhibition of viral RNA syn- 
thesis. Ribavirin aerosol therapy was pioneered in con- 
trolled studies among college students with acute in- 
fluenza virus A infections and then extended to RSV 
infections among infants. Therapeutic efficacy has been 
shown among infants and children admitted to hospital 
with and without preexisting pulmonary and cardiac 
disease. Benefits occur without significant drug toxicity, 
and five-year follow-up evaluations show no effects of 
the aerosol therapy on the respiratory tract. 

High concentrations of ribavirin are delivered in an 
aerosol by a small-particle aerosol generator through a 
mask, tent, or endotracheal tube over a 12- to 18-hour 
treatment period per day for three to five days or, in 
some cases, longer. The respiratory staff needs to give 
careful attention to drug precipitation in the respiratory 
equipment during therapy, especially among patients 
with endotracheal tubes in place. 

In general, ribavirin therapy may be expected to con- 
trol chronic infections among immunocompromised 
patients and to ameliorate infections among other treated 
inpatients. The most significant result of therapy is the 
relief of hypoxemia; this may be due to the control of the 
virus infection, an inhibition of IgE-mediated responses 
by ribavirin, or both. Ribavirin aerosol therapy may be 
indicated in infants and young children with RSV infec- 
tion complicated by pneumonia, apnea, progressive 
bronchiolitis with hypoxemia, congenital heart disease, 
and chronic lung disease. 

James Connor, M.D. 

La Jolla, California 

VOLUME 53, NO. 1 



American Academy of Pediatrics Committee on Infectious Dis- 
eases: Ribavirin therapy of respiratory syncytial virus. Pediatrics 

Hall CF, McBride JT, Walsh EE, et al: Aerosolized ribavirin treat- 
ment of infants with respiratory syncytial virus infections: A random- 
ized double blind study. N Eng J Med 1983;308:1443-7. 

McIntosh KM: Respiratory syncytial virus infections in infants and 
children: Diagnosis and treatment. Pediatr Rev 1987;9:191-6. 

Ogra PL, Patel J: Respiratory syncytial virus infection and the 
immunocompromised host. Pediatr Infect Dis 1988;7:246-9. 

Update on a-Fetoprotein Screening 

Screening of all pregnancies for neural tube and other 
birth defects, using the maternal serum ct-fetoprotein 
(AFP) level, is now a routine practice. 

AFP produced by the fetal liver appears in the mater- 
nal serum in a measurable quantity by the 15th com- 
pleted week and increases in concentration until term. 
Maternal serum AFP results are reported as multiples of 
the median value for a given gestational age and, as such, 
have provided a number of insights into conditions 
affecting a fetus or pregnancy. 

The usefulness of maternal serum AFP screening is 
improved with accurate pregnancy dating when raw 
values are adjusted for race, body weight, and the pres- 
ence of insulin-dependent diabetes. The AFP levels can 
be raised or lowered in maternal serum by several condi- 
tions affecting fetal production or transplacental or 
amniotic diffusion. These conditions include multiple 
gestations; fetal demise; and structural fetal defects such 
as open spina bifida, gastroschisis, and omphalocele. It is 
necessary, therefore, to examine carefully the pregnan- 
cies of women having abnormal AFP values. This begins 
with ultrasonography to confirm the gestational age and 
the presence of a single fetus that is viable and has no 
structural defect. A woman with an abnormal elevation 
unexplained by ultrasonography should have a specimen 
of amniotic fluid collected for karotyping and AFP 
determination. If the AFP level is elevated, the acetyl- 
cholinesterase, an enzyme specific for neural tissue, is 
assayed. An elevation supports a diagnosis of open spina 

The test should be done at a university or a referral 
laboratory with a large enough volume and experience to 
guarantee an accurate analysis and interpretation. The 
test is available in most states. California has pioneered 
and administered a statewide program that has screened 
more than 500,000 women. This program has proved to 
be cost-effective. The cost of care saved by termination 
or early treatment is about twice the cost of detection. 
Following this protocol, approximately 95% of anence- 
phalic fetuses, 80% of those with open spina bifida, and 
many fetuses with ventral wall defects could be detected 

For several years women older than 35 years at term 
have been offered an amniocentesis for the prenatal 
detection of Down’s syndrome. Because fetuses with the 

Down syndrome usually produce less AFP, low mater- 
nal serum AFP levels can now be used in women 
younger than 35 to identify an additional group of tri- 
somic fetuses. The combination of maternal age and 
serum AFP levels in multiples of the median can be used 
to assign specific risk figures. Women with a risk equi- 
valent to 35 years should be offered an amniocentesis. 
About 15% to 20% of cases of Down’s syndrome are 
detectable by this method. 

George Cunningham, M.D. 

Berkeley, California 


DiMaio MS, Baumgarten A, Greenstein RM, et al: Screening for 
fetal Down’s syndrome in pregnancy by measuring maternal serum 
alpha-fetoprotein levels. N Engl J Med 1987;317:342-6. 

Lustig L, Cunningham GC, Tompkinson G, et al: California’s exper- 
ience with low Ms-AFP results. Am J Med Genet , in press. 

Wald NJ, Cuckle HS: Recent advances in screening for neural tube 
defects and Down’s syndrome. Balliere’s Clin Obstet Gynaecol 1987; 

Varicella Vaccine Update 

The first report of varicella vaccine appeared in The 
Lancet a decade and a half ago. Since that time the 
vaccine has been licensed for use in Japan and in Europe. 
In the United States, the vaccine has been evaluated in 
thousands of normal children and in hundreds of normal 
adults and children with leukemia. Why has the vaccine 
not been licensed in this country? Varicella vaccine has 
been shown to confer good protection in healthy child- 
ren and to modify or prevent disease in adults and in 
children with leukemia. In the latter groups, its use cer- 
tainly reduces the morbidity that varicella is known to 
produce in these persons. In children with leukemia, 
there have been some reactions to the vaccine that are 
difficult to predict. In healthy children the vaccine is safe. 

The main concern appears to be about the long-term 
effects of immunization: whether the vaccine will result 
in more or less zoster than in patients with natural 
infection. Studies in children with leukemia, however, do 
not suggest that there is increased risk, and, indeed, 
zoster may be less frequent in vaccinees. Another con- 
cern is whether the widespread use of the vaccine will 
result in a greater frequency of adult cases of varicella. 
This might occur if vaccine-induced immunity wanes or 
if the epidemiology of varicella is changed by reducing 
the opportunities for natural infection in those children 
who are not immunized. By combining the varicella 
vaccine with a vaccine that is given to virtually all child- 
ren, such as the measles, mumps, and rubella vaccine, the 
latter concern can be assuaged. This combination has 
been shown to be safe and effective. 

It is unlikely that we will have additional answers to 
these possible problems by more testing. A decision on 
licensure is probably at hand. 

Philip A. Brunell, M.D. 

Los Angeles 




Brunell PA: Varicella vaccine — Where are we? Pediatrics 1986; 

Brunell PA, Novelli VM, Lipton SV, et al: Combined vaccine 
against measles, mumps, rubella, and varicella. Pediatrics 1988; 

Brunell PA, Taylor-Weideman J, Geiser CF, et al: Risk of herpes 
zoster in children with leukemia: Varicella vaccine compared with 
history of chickenpox. Pediatries 1986;77:53-6. 

Pediatric Physical Assessment of 
Sexual Abuse 

Child sexual abuse has been increasingly recognized in 
recent years. While physicians are sensitive to the psycho- 
logical and social aspects of the medical evaluation, they 
need to be aware of the medical findings on physical 
examination associated with genital trauma and to under- 
stand the significance of sexually transmitted diseases in 
prepubescent children. 

There is normal variation in the anatomy of the ano- 
genital area of prepubescent children. Not all changes 
in the genital area are due to sexual abuse. 

In general, the genital area of a prepubescent girl 
contains thin, fine structures that are scarred as a result 
of certain types of injuries. Not all forms of sexual abuse 
result in observable findings. Oral-genital contact and 
gentle fondling, for example, may result in no changes. 
External rubbing, also called vulvar coitus or dry inter- 
course, characteristically results in changes in the area of 
the posterior fourchette and occasionally hyperpigmenta- 
tion of the labia majora. Actual penetration with either 
finger, penis, or foreign object will usually lead to 
disruptions in the configuration of the hymen. With a 
single isolated episode, the initial signs of trauma may 
heal within one to two weeks, and there may be minimal 
residual findings. With repeated episodes, the traumatized 
area may not have sufficient opportunity to heal, and 
greater changes are noted. In summary, the changes 
noted with repeated vaginal penetration are a reduced 
hymenal remnant; irregularities in the hymenal contour 
representing healed tears; rounding and thickening of the 
hymen; missing portions of the hymen; and a gaping 
patulous introitus. There has been controversy concern- 
ing the size of the hymenal orifice as an indication of 
sexual abuse. In general, the orifice is 3 to 4mm in girls 
younger than 5 years and up to 5 to 6mm in girls between 
5 and 10 years old. There is no consensus about these 
measurements, however, and the finding of an enlarged 
orifice without other changes may not be diagnostic of 

Repeated penetration of the anus may lead to physical 
findings in only 50% of the victims. Scarring, thickening, 
and hyperpigmentation of the perianal skin; a diminution 
in the number of rugae; a loss of tone; and a loss of 
subcutaneous supporting tissue may be present. 

The presence of a sexually transmitted disease also 
supports the diagnosis of sexual abuse. These diseases 

include gonorrhea, Chlamydia, Trichomonas, syphilis, 
condylomata acuminata, and herpes simplex type 2. The 
presence of any of these diseases warrants further medical 
and psycho-social evaluation. 

Referral centers with expertise in pediatric sexual 
abuse may assist a clinician through experienced inter- 
viewers and with the aid of colposcopy, which provides 
magnification for a visual examination of the injured 
genital tissue. 

Carol Berkowitz, M.D. 

Torrance, California 


Berkowitz CD: Sexual abuse of children and adolescents. Adv 
Pediatr 1987;37:275-312. 

Kempe RS, Kempe CH: The Common Secret — Sexual Abuse of 
Children and Adolescents. New York, WH Freeman, 1984. 

Neinstein LS, Goldenring J, Carpenter S: Nonsexual transmission 
of sexually transmitted diseases: An infrequent occurrence. Pediatrics 

Jaundice in Healthy Newborns— 

Redefining Physiologic Jaundice 

Because clinical jaundice becomes apparent at serum 
bilirubin levels of about 5mg per dl, about 65% of all 
normal newborn infants appear jaundiced during the 
first week of life. Although the overwhelming majority of 
these infants are healthy, the presence of jaundice en- 
genders anxiety in parents and physicians alike, and the 
management of what in most cases is a “nondisease” is 
emotionally and financially draining. Most pediatricians 
follow the advice of standard pediatric texts and do 
diagnostic investigations to rule out “pathologic” jaundice 
whenever the bilirubin level exceeds 12 to 12.9mg per dl. 

We studied 2,416 infants admitted consecutively to a 
well-baby nursery and found that the maximal serum 
bilirubin cencentration exceeded 21.9mg per dl in 147 
infants (6.1%). Jaundice was associated strongly with 
breastfeeding ( P =.0001) and the percentage of weight 
loss after birth ( P =.0001) as well as maternal diabetes, 
Asian race, decreased gestational age, male sex, bruising, 
and the induction of labor with oxytocin. Using logistic 
regression analysis, we calculated the risk of jaundice for 
infants with or without these “icterogenic” factors. These 
calculations permit pediatricians to predict the likelihood 
of jaundice developing in a particular infant. When 
many risk factors are present, there is a high probability 
of jaundice, and, provided the baby is otherwise healthy, 
it is probably unnecessary, almost always unrewarding, 
and certainly expensive to do a battery of laboratory 
tests. On the other hand, we should be wary of a mod- 
estly elevated serum bilirubin level in an infant with 
jaundice who has few or no icterogenic risk factors. This 
might require further investigation. 

Based on the method of feeding alone, the 95th per- 
centile for the maximal serum bilirubin concentration in 
breast-fed infants is 14.5mg per dl, whereas it is only 
11.4mg per dl for bottle-fed infants. All other factors 

VOLUME 53, NO. 1 


being equal, therefore, it should not be necessary to 
investigate a case of a jaundiced, healthy, breast-fed 
infant unless the serum bilirubin level exceeds about 
15mg per dl, whereas in a bottle-fed infant such inves- 
tigations may be indicated if the serum bilirubin level 
exceeds about 12mg per dl. Including the other risk 
factors mentioned above further refines this approach. 
We need a new definition of what is, and what is not, 
physiologic jaundice. 

M. Jeffrey Maisels, M.D. 

Royal Oak, Michigan 

Maisels MJ, Gifford K: Normal serum bilirubin levels in the newborn 
and the effect of breast-feeding. Pediatrics 1986;78:837-43. 

Maisels MJ, Gifford K, Antle CE, et al: Jaundice in the healthy 
newborn infant: A new approach to an old problem. Pediatrics 

Maisels MJ: Neonatal jaundice, chap 27, In Avery GB (Ed): 
Neonatology, pathophysiology and management of the newborn, Ed 
3. Philadelphia, JB Lippincott, 1987, pp 534-629. 

AIDS in Schools and Day-Care Centers 

American children younger than 13 years diagnosed 
with the acquired immunodeficiency syndrome (AIDS) 
numbered 934 by April 1988. The estimated number of 
cases in 1 99 1 is 3,000. Many children with AIDS are well 
enough to benefit from the developmental and educa- 
tional opportunities of day-care attendance and elemen- 
tary school education. In addition to the number of 
children with AIDS are children with the AIDS-related 
complex and those without symptoms but who are 
seropositive for antibodies to the human immuno- 
deficiency virus (HIV). Children acquiring HIV in the 
perinatal period are asymptomatic for an average of six 
to eight months. Those who acquired the infection before 
1985 from a transfusion of blood or blood products have 
had a mean incubation period of two years. Some have 
remained asymptomatic for as long as seven years. 

The enrollment of these children in child-care settings 
and elementary schools has raised concern among those 
providing these services. Child-care and school issues 
requiring physicians’ responses include the communi- 
cability of HIV to healthy children and staff, mandatory 
serologic screening, the potential for secondary infections 
in children with AIDS, and conflicting obligations to 
protect privacy and to inform. 

Responses to such concerns are based on the current 
understanding of HIV communicability. The nonsexual 
household transmission of HIV is rare; the few reported 
cases involve extraordinary circumstances and poor 
adherence to hygienic precautions. Not one case of HIV 
infection has been transmitted in a school or day-care 
setting. Although HIV has been identified in saliva, 
tears, and urine, there is no evidence that these fluids are 
involved in the transmission of the infection. 

Casual contact as would occur among children in an 
elementary school should not be considered a risk for the 
communicability of HIV. The benefits of unrestricted 

school attendance to most school-aged children seropos- 
itive for HIV outweigh any remote risk of viral transmis- 
sion. HIV-seropositive infants, toddlers, and older child- 
ren with subnormal development are more likely to lack 
control of their body secretions and to practice frequent 
hand- and object-mouthing behaviors and biting behav- 
iors. These children and HIV-seropositive children with 
oozing skin lesions hypothetically pose an increased risk 
to others. For these cases, exclusion from a group pro- 
gram should be decided on a case-by-case basis by quali- 
fied persons including the child’s physician and a person 
familiar with the educational setting. 

Hygenic practices in day-care centers and schools can 
contain the spread of infectious diseases and are recom- 
mended in the presence or absence of known HIV- 
infected persons. Child-care personnel and educators 
can minimize their exposure to HIV by carefully attend- 
ing to hand washing. In regions with a high prevalence of 
HIV infection, consideration should be given to protect- 
ing open skin lesions and dry, cracked skin with dispos- 
able gloves when handling body fluids and excrement. 
Caution in disposing of soiled towels, diapers, and sani- 
tary napkins must become routine. Soiled surfaces and 
mops should be cleaned with disinfectants (household 
bleach diluted 1:10 with water). 

Mandatory screening for HIV as a condition for 
school or day-care enrollment is unwarranted. A physi- 
cian, not the educational facility, should be responsible 
for assessing the risk of secondary infection to an HIV- 
positive child who may be immunosuppressed. Notifying 
school personnel of a child’s HIV status would expedite 
preventive action by the parent or physician of an 
immunocompromised HIV-positive student when there 
is a school epidemic. The cost of even limited disclosure, 
however, will often be the needless ostracism of the child 
from school. Information about a child’s immunodefi- 
ciency, regardless of its cause, should be disclosed to 
certain care givers, but a child’s HIV-seropositive status 
is to remain confidential information. Exceptions may 
be to inform those staff members who directly care for 
children with frequent biting behavior or children incap- 
able of controlling body secretions. 

The responsibility of the schools goes beyond safely 
enrolling HIV-seropositive children in their classrooms. 
Given that vaccine development is not imminent, com- 
munity education is the most efficient means of control- 
ling the spread of HIV, and schools have the capability 
and responsibility to provide this education. Guidelines 
for an educational curriculum directed towards various 
grade levels are available from the Centers for Disease 
Control to educators who want an effective strategy to 
teach students how to avoid HIV infection. 

Howard Taras, M.D. 

San Diego 


American Academy of Pediatrics Committee on Infectious Dis- 



eases: Health guidelines for the attendance in day-care and foster care 
settings of children infected with human immunodeficiency virus. 
Pediatrics 1987;79:466-71. 

American Academy of Pediatrics Committee on School Health and 
Committee on Infectious Diseases: School attendance of children and 
adolescents with human T lymphotropic virus III/lymphadenopathy- 
associated virus infection. Pediatrics 1986;77:430-2. 

Guidelines for effective school health education to prevent the 
spread of AIDS. MMWR 1988;37(S2): 1-14. 

Rogers MF, Thomas PA, Starcher ET, et al: Acquired immunodefi- 
ciency syndrome in children: Report of the Centers for Disease Control 
national surveillance 1982 to 1985. Pediatrics 1987;79:1008-14 

Management and Ethical Dilemmas 
of Diagnosing and Treating Fetal 
Heart Disease 

Major advances in ultrasound imaging over the past 
ten years currently provide a systematic approach to 
evaluating the anatomy, physiology, and rhythm of the 
fetal heart, with detailed imaging available as early as the 
14th to the 15th week of pregnancy. Pediatric cardiolo- 
gists, perinatologists, and radiologists, often working 
together, have diagnosed almost every major form of 
congenital heart disease correctly before birth. Such no- 
table success has not come easily, and, in general, physi- 
cians working in this area have often required two to five 
years of extensive experience to achieve proficiency 
using ultrasound for a detailed cardiovascular evalua- 
tion before birth. 

Indications for fetal cardiac ultrasonography include 
maternal diabetes, maternal drug exposure, maternal 
infection, a family history of congenital heart disease in a 
parent or sibling, or persistent fetal arrhythmia. The 
largest “pick-up” rate for major forms of congenital heart 
disease will occur if obstetricians evaluate a four-chamber 
cardiac view as a part of their routine obstetric ultrason- 
ographic screening procedure. They should see the atrial 
and ventricular septa and four chambers relatively sym- 
metrically dividing the cardiac ultrasound “sil- 
houette” in this plane. Perhaps 90% of the major forms 
of congenital heart disease can be ruled out by a normal 
four-chamber view. 

Alternatives available in the aftermath of the diagnosis 
of congenital heart abnormality may include pharma- 
cologic therapy for an arrhythmia; counseling a family 
about the natural history — catheterization, heart opera- 
tions, and the like — of infants with similar forms of 
congenital heart disease after birth; and counseling 
related to terminating a pregnancy in the appropriate 
circumstance or making arrangements for the timing and 
method of delivery for the appropriate medical or surgi- 
cal intervention after birth, including consideration of a 
neonatal heart transplantation for certain inoperable 
conditions. Major additional capabilities for evaluating 
the fetal heart have arisen with the application of the 
Doppler to evaluate cardiac function in cases of valvular 
disease, and high-resolution color flow mapping has 
assisted in evaluating septal defects as well as the aortic 

arch and conal truncal abnormalities. 

The field of fetal cardiology is rapidly advancing. It 
requires the highest level of technical skills and coopera- 
tion among obstetric, pediatric, neonatal, ethical, legal, 
genetic, and surgical colleagues. Several tertiary hospi- 
tals have developed centers for fetal diagnosis and treat- 
ment where such multidisciplinary expertise can be coor- 
dinated, not only for cardiac but for other organ system 
diseases diagnosed and potentially treated in the fetal 
stage. Through regionalized team efforts, advances in 
this dynamic area of fetal medicine will be controlled and 
yet nurtured to encourage further advances. 

David J. Sahn, M.D. 

San Diego 


Allan LD, Crawford DC, Anderson RH, et al: Spectrum of congeni- . 
tal heart disease detected echocardiographically in prenatal life. Br 
Heart J 1985;54:523-6. 

Kleinman CS, Donnerstein RL, Jaffe CC, et al: Fetal echo- 
cardiography — A tool for evaluation of in utero cardiac arrhythmias 
and monitoring of in utero therapy: Analysis of 71 patients. Am J 
Cardiol 1983;51:237-43. 

Reed KL, Sahn DJ : A proposal for referral patterns for fetal cardiac 
studies. Semin Ultrasound CT MR 1984;5:249-52. 

Sahn DJ: Real-time two-dimensional Doppler echocardiographic 
flow mapping. Circulation 1985;71:849-53. 

Sahn DJ, Lange LW, Allen HD, et al: Quantitative real-time cross- 
sectional echocardiography in the developing normal human fetus and 
newborn. Circulation 1980;62:588-97. 

Silverman N, Kleinman CS, Rudolph AM, et al: Fetal atrioventricu- 
lar valve insufficiency associated with nonimmune hydrops: A two- 
dimensional echocardiographic and pulsed Doppler ultrasound study. 
Circulation 1985;72:825-32. 

Exogenous Surfactant for the Respiratory 
Distress Syndrome 

Since the 1970s, therapy for the neonatal respiratory 
distress syndrome has focused on metabolic resuscita- 
tion and assisted ventilation of preterm infants with 
ventilatory failure until the gene controlling surfactant 
production and secretion is activated. Surfactant defi- 
ciency is central to the pathophysiology of the respira- 
tory distress syndrome. Successful exogenous surfactant 
administration has led to the development of several 
promising surfactants for exogenous use. 

Human surfactant, derived from amniotic fluid, con- 
tains all surfactant proteins (SP-A, -B, and -C), phospho- 
lipods identical to “mature” adult surfactant, and a small 
percentage of neutral lipids. Human surfactant instilled 
into the airways has been shown to reverse ventilatory 
failure from the respiratory distress syndrome; to bring 
about a rapid improvement in oxygenation; and, in very 
premature infants, to decrease the mortality and the 
prevalence of bronchopulmonary dysplasia. 

Several “first-generation” surfactants have shown 
promise in clinical trials. Surfactant TA, calf lung surfac- 
tant extract, and human surfactant are currently being 
evaluated in multidose clinical trials to establish efficacy 
and safety. Synthetic surfactant, not derived from natu- 

VOLUME 53, NO. 1 


ral sources and void of surfactant protein (Exosurf), is 
concurrently being studied in similar trials. Both preven- 
tilatory treatment and postventilatory “Rescue” trials of 
surfactant treatments are being systematically investi- 
gated using these surfactants. Using human surfactant 
has thus far been free of complications, and the two-year 
neurodevelopment follow-up evaluation suggests an 
overall improvement in treated infants. 

Critical advances in isolating surfactant components 
and cloning suggest that recombinant surfactants, com- 
prising critical proteins or biologically active peptides 
and phospholipid mixtures in ideal combinations, will 
become “second-generation” surfactants. 

Until the efforts of genetic engineering are successful, 
neonatologists will be limited to using natural surfactant 
derivatives or artificial surfactants in carefully controlled 
trials sanctioned by the Food and Drug Administration. 
Of course, only premature infants with evidence of sur- 
factant deficiency should receive this experimental ther- 
apy. If the present trials are successful, surfactant ther- 
apy should by 1990 become a mainstay of the treatment 
of the respiratory distress syndrome. 

T. Allen Merritt, M.D. 

Mikko Hallman, M.D. 

San Diego 


Edwards DK, Hilton SV, Merritt TA, et al: Respiratory distress 
syndrome treated with human surfactant: Radiographic findings. 
Radiology 1985;157:329-34. 

Fujiwara T, Chida S, Watabe Y, et al: Artificial surfactant therapy in 
hyaline-membrane disease. Lancet 1980;1:55-9. 

Hallman M, Merritt TA, Jarvenpaa AL, et al: Exogenous human 
surfactant for treatment of severe respiratory distress syndrome: A 
randomized prospective clinical trial. J Pediatr 1985;106:963-9. 

Merritt TA, Hallman M, Bloom BT, et al: Prophylactic treatment of 
very premature infants with human surfactant. N Engl J Med 

Revak SD, Merritt TA, Degryse E, et al: Use of human surfactant 
low molecular weight apoproteins in the reconstitution of surfactant 
biologic activity. J Clin Invest 1988;81:826-33. 

Vaucher YE, Merritt TA, Hallman M, et al: Neurodevelopmental 
and respiratory follow-up in early childhood following human surfac- 
tant treatment. Am J Dis Child, in press. 

Bronchopulmonary Dysplasia (Infantile 
Chronic Lung Disease) 

With the increased survival of neonates who have 
severe respiratory insufficiency, bronchopulmonary 
dysplasia has become an important cause of chronic 
illness during the first five years of life. Causes of respira- 
tory tract injury in early infancy that may lead to bron- 
chopulmonary dysplasia include lung immaturity (hya- 
line membrane disease); aspiration syndromes; infection, 
especially viral; and respiratory tract malformations 
associated with impaired mucociliary function and 
chronic airways soilage. These infants survive with 
impaired mucociliary clearance mechanisms, increased 
bronchial reactivity and bronchomotor tone, and im- 
paired lung water dynamics. 

While diuretic and bronchodilator therapy continue 
to be mainstays of management, recent studies have 
shown the importance of adequate oxygenation for the 
recovery from bronchopulmonary dysplasia. Maintain- 
ing an arterial oxygen tension above 85 torr is desirable. 
Occult, sometimes life-threatening hypoxemia has re- 
cently been described in patients with bronchopulmo- 
nary dysplasia who have relatively mild clinical disease. 
Such infants benefit from a predischarge evaluation of 
gas exchange in all activity states by continuous trans- 
cutaneous monitoring of blood gas measurements so 
that supplemental oxygen can be prescribed for vulnera- 
ble periods during daily activities. 

Lung reinjury must be avoided. Intercurrent infec- 
tions — including extrapulmonary infections — should be 
treated aggressively, and influenza prophylaxis and 
treatment should be undertaken for any infants older 
than 6 months. Pertussis immunization is essential even 
for those infants receiving anticonvulsant therapy. Gas- 
troesophageal reflux must be treated aggressively to 
avoid aspiration reinjury. Environmental sources of lung 
injury such as pollution, side-stream cigarette smoke, 
and exposure to talc should be avoided. 

The recovery from bronchopulmonary dysplasia is 
associated with normal growth and repair of the respira- 
tory tract. Growth failure frequently occurs as a conse- 
quence of chronic hypoxemia, increased oxygen con- 
sumption, and an inadequate intake of protein and other 
calories compared with the increased caloric expendi- 
ture. Therefore, continuing nutritional assessment and 
management are important. 

Cheryl D. Lew, M.D. 

Los Angeles 


Bader D, Ramos AD, Lew CD, et al: Childhood sequelae of infant 
lung disease: Exercise and pulmonary function abnormalities after 
bronchopulmonary dysplasia. J Pediatr 1987; 1 10:693-99. 

Garg M, Kurzner SI, Bautista DB, et al: Oxygen desaturation during 
sleep and feeding in bronchopulmonary dysplasia. Clin Res 1987; 

Kurzner SI, Garg M, Bautista DB, et al; Growth failure in broncho- 
pulmonary dysplasia: Elevated metabolic rates and pulmonary 
mechanics J Pediatr 1 988; 1 12:73-80. 

Kurzner SI, Garg M, Bautista DB, et al: Growth failure in infants 
with bronchopulmonary dysplasia: Nutrition and elevated resting 
metabolic expenditure. Pediatrics 1988;81:379-84. 

Transient Erythroblastopenia of Childhood 

Transient erythroblastopenia of childhood (TEC) is 
characterized by the gradual development of anemia — a 
hemoglobin level of 2 to 8 grams per dl — reticulo- 
cytopenia, and a pronounced reduction of bone marrow 
erythroblasts. The platelet count is normal to increased. 
The leukocyte count is usually normal, although 20% of 
children may have significant neutropenia (less than 
1,000 neutrophils per ;ul). The disorder occurs in pre- 
viously healthy young children from 6 months to 4 years 
of age and is seen with equal frequency in boys and girls. 



Occasionally cases of the disorder occur in clusters, sug- 
gesting it may be a consequence of some seasonal envi- 
ronmental toxin or virus. To date, however, serologic 
studies have failed to reveal exposure to a common virus. 
Published data suggest that anemia is due to a transient 
antibody-mediated suppression of normal erythropoiesis. 

The natural history of TEC is that all patients recover 
spontaneously in a few weeks and there are no long-term 
hematologic sequelae. In many children with the dis- 
order, particularly if there is evidence of recovery at the 
time of diagnosis, no specific therapy other than careful 
observation is necessary. Erythrocyte transfusions are 
indicated only if a child is symptomatic from the anemia. 
Neither iron nor steroid therapy has any role in the 
management of this disorder. 

The diagnosis often is confused with that of iron defi- 
ciency anemia, although the erythrocytes in patients with 
TEC are normocytic (mean corpuscular volume [MCV], 
70 to 85 fl), whereas iron deficiency anemia is character- 
ized by microcytosis (MCV, 50 to 70 fl). Transient 
erythroblastopenia of childhood also may be confused 
with Blackfan-Diamond anemia, although the latter 
generally presents before 6 months of age, often is asso- 
ciated with congenital abnormalities, and invariably is 
characterized by macrocytic erythrocytes (MCV, 85 to 
100 fl) with many fetal-like features. Because some child- 
ren with TEC also have significant neutropenia, there 
occasionally is confusion with the diagnosis of aplastic 
anemia or acute leukemia, but this is readily clarified by 
examining the bone marrow. 

Reports recognizing TEC as a distinct disorder first 
appeared in 1970. The general impression among most 
pediatric hematologists, however, is that the incidence of 
this acquired erythrocytic aplasia in children is increas- 
ing. At our own institution, three cases of TEC were 
diagnosed from 1979 to 1982, whereas 29 children with 
TEC were seen from 1983 to 1987. Because the magni- 
tude of anemia in this disorder is usually severe, it is 
unlikely that it previously existed as an unrecognized 
condition that is now being more readily recognized. 

Bertil E. Glader, Ph.D., M.D. 

Stanford, California 


Beresford CH, MacFarlane WD: Temporal clustering of transient 
erythroblastopenia (cytopenia) of childhood. Aust Paediatr J 1987; 

Glader BE: Diagnosis and management of red call aplasia in child- 
ren. In Oski FA (Ed): Hematology/ Oncology Clinics of North Amer- 
ica, Vol 1. Philadelphia, WB Saunders, 1987, pp 431-47. 

Adolescent Suicide and Depression 

Suicide is the third leading cause of death in adoles- 
cents (aged 10 to 19 years), with a 1985 rate of about 9 
deaths per 100,000 in this population. Of all deaths 
during adolescence, 14% are a result of suicide. Rates 
differ greatly by age, race, and gender; white and Native 
American male adolescents in the 15- to 19-year-old 

group have the highest rates. Since 1960, the incidence of 
suicide has increased by 200% in the 15- to 19-year-old 
age group. The frequency of nonfatal attempts and ges- 
tures is difficult to document. It is estimated that for 
every completed suicide, there are 50 to 200 attempted 
suicides, with a female preponderance in this group as 
compared with a male preponderance in completed sui- 
cides. Cluster suicide, the occurrence of multiple suicides 
in a circumscribed geographic location during a short 
time period has recently appeared. The media have been 
implicated as an etiologic agent in these suicides because 
of imitative behavior in the suicidal acts following news- 
paper stories and televised movies. 

Methods used include firearms for boys and girls, with 
hanging and jumping as the second method for boys and 
girls, respectively. Drug overdosing is the most common 
method of attempted suicide but remains uncommon in 
completed suicides. 

Common etiologic factors include a family history of 
completed or attempted suicide, a previous suicide 
attempt, substance abuse, aggressive or impulsive behav- 
ior, depression associated with behavior problems in 
male adolescents, sexual abuse, depression, manic- 
depressive psychosis, learning disorders, and knowing 
someone who committed or attempted suicide. Certain 
precipitating events that occur before the suicide attempt 
include conflict with a parent or friend that is exper- 
ienced as rejection, anxiety over change, substance abuse, 
school problems, social isolation, hypochondriasis, preg- 
nancy, and trouble with the law. 

Depression remains the common etiologic feature in 
adolescent suicide, with reported incidence rates of 1.0% 
in boys and 1.5% in girls; yet the diagnosis in an adoles- 
cent remains difficult because the signs and symptoms 
are more often depressive equivalents and often are 
attributed to normal adolescence. Depressive equiva- 
lents include a decrement in school performance, prob- 
lems with the law, hypochondriasis, substance abuse, 
and family conflicts. Adolescent depression has three 
common features: changes in mood and relationships, 
thinking, and bodily functioning. Genetic predisposition 
is increasingly a cause of depression, especially in those 
young people whose depression begins in childhood and 

Adolescents who are depressed or contemplating sui- 
cide are difficult to engage in treatment. Special attention 
should be given to those with a family history of suicide, 
street youth, pregnant girls, and teenagers who have 
problems with the law. Intervention should focus on 
querying all adolescents about their feelings of sadness 
and suicidal ideation, informing young people about 
mental health problems and the availability of resources, 
de-emphasizing the romanticization of suicide as por- 
trayed in the media, and engaging depressed and high- 
risk adolescents in appropriate therapeutic environments. 

Charles E. Irwin, Jr, M.D. 

San Francisico 

VOLUME 53, NO. 1 



Advance report of final mortality statistics, 1984. Hyattsville, Md. 
Monthly Vital Statistics Report 1986;35(suppl 2): 1-44. 

American Academy of Pediatrics Committee on Adolescence: Sui- 
cide and suicide attempts in adolescents and young adults. Pediatrics 


Gould MS, Shaffer D: The impact of suicide in television movies: 
Evidence of imitation. N Engl J Med 1986;315:690-94. 

Hodgman CH: Recent findings in adolescent depression and suicide. 
J Dev Behav Pediatr 1985;6:162-70. 


Joan E. Hodgman, M.D. 
Advisory Panel Chair 
CM A Scientific Board Representative 

Milton D. Schwarz, M.D. 

CM A Section Chair 
Santa Ana 

Stephen A. Fernbach, M.D. 

CM A Section Secretary 
Santa Clara 

Martin T. Stein, M.D. 

CM A Section Assistant Secretary 
Section Editor 

University of California, San Diego 

John Mace, M.D. 

Loma Linda University 

Irving Schulman, M.D. 

Stanford University 

Charles F. Abilgaard, M.D. 

University of California, Davis 

Donald R. Sperling, M.D. 

University of California, Irvine 

William F. Friedman, M.D. 

University of California, Los Angeles 

Melvin Grumbach, M.D. 

University of California, San Francisco 

Bernard Portnoy, M.D. 

University of Southern California 

Birt Harvey, M.D. 

Palo Alto 

Robert L. Black, M.D. 


Anthony Hirsch, M.D. 

Los Angeles 

Louie G. Linarelli, M.D. 

San Diego 


MAY 10, 11, 1989 





Treatment of Obesity in Adults 


Concern with weight control should begin sufficiently 
early in life to reduce the risk of developing obesity. The 
complex etiology of obesity is, in part, responsible for the 
difficulty physicians encounter in treating this condition. 
Prevention is the “treatment” of choice. Early identifica- 
tion of individuals genetically at risk can be helpful in 
targeting those most likely to gain excess weight. Numer- 
ous dietary regimens have been devised in an attempt to 
achieve progressive weight loss in obese individuals. 
Since the ultimate goal of a weight-reduction program is 
to lose weight and maintain the loss, a nutritionally 
balanced, low-energy diet that is applicable to the 
patient’s life-style is most appropriate. Increasing energy 
expenditure through physical activity, in addition to 
decreasing energy intake, generally improves results in 
the management of obesity. Major changes in eating and 
exercise behaviors are necessary to ensure long-term 
weight control. Diet, exercise, and behavior modifica- 
tion are interdependent and mutually supportive. A 
comprehensive weight-reduction program that incorpo- 
rates all three components is more likely to lead to 
long-term weight control. 

T HIS report assesses the role of diet, physical activity, 
and behavior modification in the treatment of obe- 
sity in adults. It does not discuss the use of anorexiants, 
which is covered in Drug Evaluations , 1 or surgical man- 
agement of morbid obesity (ie, twice or more the average 
desirable body weight). 2 

Obesity can be defined as an excessive accumulation 
of fat in the body. Measurements of body fat require 
sophisticated techniques that are not widely available 
(eg, measurements of body density, determination of 

From the Council on Scientific Affairs, American Medical Associa- 
tion, Chicago. 

This report was presented to the House of Delegates of the American 
Medical Association at the December 1987 Interim Meeting as an 
informational report of the Council of Scientific Affairs. 

This report is not intended to be construed or to serve as a standard 
of medical care. Standards of medical care are determined on the basis 
of all the facts and circumstances involved in an individual case and are 
subject to change as scientific knowledge and technology advance and 
patterns of practice evolve. These reports reflect the views of scientific 
literature as of December 1987. 

total body fat or water by isotopic or chemical dilution). 
In clinical practice, anthropometric measurements based 
on height, weight, and skinfold thickness are recom- 
mended. 3 For practical purposes, it is generally agreed 
that obesity is probably present if body weight is 20% or 
more above “desirable weight” (based on actuarial data 
on height and body weight at various ages). 4 For pur- 
poses of this discussion, desirable weight is defined as the 
midpoint of the range for medium-frame individuals as 
shown in the 1983 Metropolitan Height and Weight 
Tables (Table). 5 The first National Health and Nutrition 
Examination Survey, conducted between 1971 and 1974, 
found that 28.8 million adults were obese, 8.4 million of 
whom were severely obese. 6 The second National Health 
and Nutrition Examination Survey, conducted between 
1976 and 1980, found that 34 million US adults were 
overweight, 13 million of whom were severely over- 
weight. 7 Overweight was defined as 20% above desirable 
weight and severely overweight as 40% above desirable 

Obesity is associated with a number of health hazards. 
It may impair both cardiac and pulmonary function, 
modify endocrine function, and cause emotional prob- 
lems. Hypertension, impaired glucose tolerance, and 
hypercholesterolemia are more common in overweight 
individuals than in individuals of normal weight. 6 Thus, 
it is not surprising that obesity may contribute to mor- 
bidity and mortality in individuals with hypertension, 
stroke, type II or non-insulindependent diabetes melli- 
tus, some types of cancer, and gallbladder disease. 1 Over 
the long term, obesity is also considered an independent 
risk factor for atherosclerotic heart disease. 1 

The complex etiology of obesity is in part responsible 

Members of the Council on Scientific Affairs include the following: 
George M. Bohigian, M.D., St. Louis, Chairman; E. Harvey Estes, Jr., 
M.D., Durham, NC; Ira R. Friedlander, M.D., Chicago, Resident 
Representative; William R. Kennedy, M.D., Minneapolis; John H. 
Moxley III, M.D., Los Angeles, Immediate Past-Chairman; Patricia J. 
Numann, M.D., Syracuse, NY; Paul S. Salva, Ph.D., Lubbock, Tex., 
Medical Student Representative; William C. Scott, M.D., Tucson, 
Vice-Chairman; Joseph H. Skom, M.D., Chicago; Richard M. 
Steinhilber, M.D., Cleveland; Jack P. Strong, M.D., New Orleans; 
Henry N. Wagner, Jr., M.D., Baltimore; William R. Hendee, Ph.D., 
Secretary; William T. McGivney, Ph.D., Assistant Secretary; and 
Therese D. Mondeika, R.D., Staff Author. 

VOLUME 53, NO. 1 


for the difficulty physicians encounter in treating this 
condition. Despite a multitude of programs designed to 
treat obesity, success in treatment often is difficult to 
achieve. If a “cure” for obesity is defined as reduction to 
desired weight and maintenance of that weight for five 
years, it is more likely that a person will be cured of most 
forms of cancer than obesity. 8 

For many persons, obesity is largely a result of life- 
style, of patterns of eating and physical activity, and of 
firmly established cultural patterns and social and eco- 
nomic forces. 



Weight, lb 

































































































































































*Source of basic data: 1979 Build Study, Society of Actuaries and 
Association of Life Insurance Medical Directors of America, 1980. 
Courtesy of Statistical Bulletin, Metropolitan Life Insurance Company. 

Some individuals may have a genetic propensity to 
become obese. 4 Concern with weight control should 
begin sufficiently early in life to reduce the risk of devel- 
oping obesity. Genetic influences appear to have an 
important role in determining human fatness and obes- 
ity. 9 ? 10 Prevention is the “treatment” of choice. Early 
identification of individuals genetically at risk can be 
helpful in targeting those most likely to gain excess 

Every obese individual presents a unique problem that 
is influenced by factors such as degree of excess weight, 
age, and severity of associated disorders, as well as 

developmental patterns, family history, eating and activ- 
ity patterns, and fat distribution or body shape. If treat- 
ment is to be successful, the patient must be strongly 
motivated to participate in a weight reduction program. 
Motivators may be psychological (eg, feelings of inade- 
quacy, difficulty in buying fashionable clothing) or phys- 
ical (eg, joint pain). Substantial weight reduction often 
can be achieved when the alternative to weight loss 
entails clearly defined penalties, ie, when excess weight 
constitutes a health hazard or leads to appreciable mor- 
bidity.The physician has a responsibility to explain the 
rationale for advising weight loss and its importance to 
health. 11 The emphasis on slimness in women in our 
society, encouraged to a large degree by the advertising 
media, has created unrealistic expectations of desirable 
body weight. Preoccupation with extreme slimness can 
create an environment conducive to anorexia nervosa 
and/or bulimia in some women. 

A realistic goal for weight loss should be established 
for each individual to prevent disillusionment and, ulti- 
mately, abandonment of efforts. A kilogram of adipose 
tissue provides the energy equivalent of 29 400 kJ (7000 
kcal). 11 A realistic rate of weight loss should be estab- 
lished for each individual depending on height, weight, 
age, and degree of obesity. For most patients, a rate of 
weight loss of about 1% of body weight per week is 
appropriate. Helping the patient to understand that 
there is no quick remedy for obesity helps to ensure 
realistic expectations of weight loss. 

Dietary Treatment 

Numerous dietary regimens have been devised in an 
attempt to achieve progressive weight loss in obese indi- 
viduals. Weight loss occurs only when energy expendi- 
ture exceeds intake. Although physical activity plays an 
important role in balancing the equation between energy 
intake and expenditure, the mainstay of weight loss is 
restriction of energy intake. 


Fasting as a treatment modality for obesity, particu- 
larly morbid obesity, has been used for more than 70 
years; however, few studies on the overall benefits of 
weight reduction by this method have been published. 
Fasting programs conducted under medical supervision 
have produced variable and sometimes contradictory 
results. 12 Short periods of fasting have not been success- 
ful in morbidly obese subjects; prolonged fasting, at best, 
is of temporary benefit. Weight is regained by a majority 
of patients and, in some cases, the former weight is 
exceeded. 12 

Because total fasting may produce a number of adverse 
effects, including severe ketosis, hyperuricemia, exces- 
sive loss of lean body mass, hyponatremia, hypokalemia, 
hypoglycemia, neutropenia, alopecia, and increased renal 
loss of phosphate and magnesium, 13 close medical 
supervision is necessary for prolonged total fasting. 
Although rapid, uninterrupted weight loss occurs with a 



prolonged fast, fasting may be hazardous, offers no 
benefits over other weight-reduction regimens, and does 
not control weight over an extended period. 

Very Low- Energy Diets 

The adverse effects associated with total fasting led to 
the development of “protein-sparing modified fasts” and 
other very low-energy diets (<2520 kJ / d[<600 kcal/ d]). 
These diets provide protein of high biologic value and are 
usually prescribed for severely or morbidly obese adults. 
The purpose of these diets is to produce a rapid weight 
loss while preserving lean body mass by providing die- 
tary protein or protein with carbohydrate. 

Much adverse publicity was associated with liquid 
protein diets that were promoted to the public in the 
mid-1970s. Preparations consisting of low-energy pre- 
digested liquid collagen provided protein of low biologic 
value and were sold over the counter for the treatment of 
obesity. By the end of 1977, approximately 60 deaths had 
been attributed to these diets; 14 17 of the fatalities were in 
individuals who had used the liquid protein diets as their 
sole source of nutrition for longer than two months; 
ventricular arrhythmias were thought to be the imme- 
diate cause of death. 14 More recent evidence 14 indicates 
that very low-energy diets that provide protein of high 
biologic value and are supplemented with vitamins and 
minerals may be safer, when properly supervised, than 
the now abandoned liquid protein regimens. 

Two types of commonly used very low-energy diets 
are (1) the so-called protein-sparing modified fast that 
provides approximately 1.5g of protein per kilogram of 
desirable body weight daily and (2) a liquid formula diet 
that provides approximately 33 to 70g of protein daily. 15 
The former diet eliminates all carbohydrates, and the 
only source of fat is that obtained from lean meat, fish, 
and poultry, the only foods permitted in the diet. The 
liquid diet consists of a milk- or egg-based formula that, 
in addition to the protein, may include approximately 30 
to 45g of carbohydrate and about 2g of fat. Supplemen- 
tation with vitamins and minerals is required with both 
types of diets. Comparable results have been achieved 
with both types of diets. 15 Treatment of more than 10 000 
persons has shown that very low-energy diets produce 
large weight losses, which are directly proportional to the 
duration of treatment. 16 Weight losses of 20kg in 12 
weeks can be attained. These diets should always be 
supervised by physicians who have knowledge of the 
metabolic consequences of the regimen. 16 

In conclusion, use of very low-energy diets should be 
restricted to persons with severe obesity; these individu- 
als should have an appropriate cardiac evaluation in the 
initial screening and remain under medical supervision. 14 
The appeal of the impressive weight loss achieved with 
these diets, however, is severely limited by the seeming 
inability of patients to sustain their weight loss. There- 
fore, attention must be directed to maintenance pro- 
grams after the desired weight loss is achieved. 

Balanced vs Unbalanced 
Low-Energy Diets 

The nutritionally balanced low-energy diet provides a 
conventional distribution of the macronutrients, ie, car- 
bohydrates (>50% of total energy intake), protein (15% 
to 20%), and fat (<30%). The usual range of energy 
intake for such diets is 4200 to 5040 kJ/d (1000 to 1200 
kcal/d). When energy intake falls below these levels, it is 
very difficult to obtain the recommended levels of certain 
nutrients, such as iron, calcium, magnesium, vitamin B 6 , 
zinc, and copper, without marked alterations in food 
choices. 17 Therefore, vitamin and mineral supplementa- 
tion is usually necessary under these circumstances. 18 
Since the ultimate goal of any weight-reduction program 
is to lose weight and maintain the loss, it would appear 
that a nutritionally balanced low-energy diet composed 
of conventional foods that are easily obtained and eco- 
nomically feasible would help meet the objective. 

Unbalanced low-energy diets place particular empha- 
sis on one or more specific macronutrients while restrict- 
ing others. Low-carbohydrate diets predominate in this 
category. The physiological responses of individuals to 
such diets vary widely and depend on factors such as the 
nutritional status of the individual, the energy content of 
the diet, and, to some extent, the individual amounts and 
proportions of the energy-producing nutrients they con- 
tain. 19 

There is no evidence that altering the proportions of 
energy-providing nutrients will have metabolic effects 
that accelerate or retard the loss of body fat beyond that 
attributable to the energy deficits generated. 17 The initial 
rates of weight loss and fluid balance can be affected by 
the relative proportions of the energy-producing nu- 
trients. For example, diets low in both carbohydrates 
(< 100 g) and energy value are likely to result in diuresis, 
which might be construed erroneously as loss of body fat 
during the initial stages of a weight-reduction program. 
Although low-carbohydrate diets may be effective as a 
short-term approach to weight loss, weight is regained 
once carbohydrate intake is increased. Furthermore, 
these diets may be associated with fatigue, nausea, ortho- 
static hypotension, dehydration, and electrolyte im- 

Novelty Diets 

There are many novelty diets promoted as “revolu- 
tionary” or “guaranteed 100% successful” in weight reduc- 
tion. Most of these diets rely on specific foods or food 
combinations to facilitate weight loss (eg, the grapefruit 
diet, the banana and skim milk diet), and they are fre- 
quently deficient in important nutrients. 20 These diets 
imply that a specific food or combination of foods selec- 
tively oxidizes body fat, increases metabolic rate, or 
inhibits voluntary food intake. 20 Weight can be lost on 
these diets but not for the reasons stated. In general, 
these diets cause weight loss by reduction of energy 
intake, frequently below 4200 kJ/d (1000 kcal/d). Once 

VOLUME 53, NO. 1 


the weight is lost, however, little, if any, attention is given 
to a weight-maintenance plan, and the individual is likely 
to regain the weight. 

Physical Activity 

Increasing energy expenditure in addition to decreas- 
ing energy intake generally improves results in the man- 
agement of obesity. Exercise alone, however, may de- 
crease body weight without alterations in the diet except 
in severely obese patients with hyperplastic adipose tis- 
sue. Body fat in these individuals decreases very slowly or 
not at all with exercise. 21 The metabolic aspects of exer- 
cise and weight reduction pertaining to resting metabolic 
rate, food intake, and thermogenesis will be discussed 

Resting Metabolic Rate 

There has been renewed interest in the question of 
whether exercise alters the resting metabolic rate (RMR). 
It has been shown that the RMR and total daily expendi- 
ture are elevated in those who are obese. 22 Because the 
RMR is associated with metabolically active tissue, it 
can be expected that the RMR, and therefore total 
energy expenditure, will decrease as body cell mass di- 
minishes during a program of weight reduction. 23 Declines 
in metabolic rates with fasting and seminstarvation have 
been shown to be greater than could be accounted for by 
the loss of lean body mass alone. 24 

The rate of weight loss decreases with time when an 
individual is adhering to a diet in which energy intake is 
reduced. This has been attributed to the decrease in the 
RMR that occurs with restriction of energy intake. 22 
There is a decline in energy expenditure when energy 
intake is reduced. This may be attributed to the following 
factors: (1) loss of lean body mass, which results in a 
decreased RMR; (2) decreased cost of physical activity 
due to a lower body weight; and (3) lower thermogenic 
effect of food related to the lower energy intake. 22 These 
factors may contribute to the plateau observed in weight- 
reduction programs that focus primarily on energy re- 

There is no general agreement on the effects of exercise 
on the RMR, but some preliminary data indicate that 
the decrease in the RMR that normally occurs when 
individuals are on low-energy diets may be prevented or 
reduced by incorporating physical activity into the pro- 

Effect on Food Intake 

Studies in rats have demonstrated that low levels of 
physical activity are commensurate with decreased food 
intake whereas high levels of physical activity are com- 
mensurate with increased food intake. 25 However, it is 
difficult to evaluate the relationship between energy 
expenditure and energy intake in human studies. 

There appears to be very little relationship between 
energy expenditure and food intake during short peri- 
ods. During an extended period, however, some degree 
of regulation does take place. For example, individuals 

engaged in strenuous activities (farmers or athletes) have 
very high levels of energy expenditure with high energy 
intakes and yet are able to maintain body weight with a 
low percentage of body fat. 25 

Studies 26 ’ 27 on the effect of physical activity on energy 
intake in obese women have shown that moderate exer- 
cise was not accompanied by increased energy intake, 
thus resulting in a negative energy balance and weight 

Effect on Thermogenesis 

It has been proposed that the thermogenic response to 
food, which is not more than 10% to 15% of the energy 
value of the ingested food, interacts with exercise and 
increases heat production. 28 The extent to which this 
occurs and the differences in thermogenic response be- 
tween lean and obese individuals are not entirely clear. 

Investigations into the potentiation of the thermic 
effect of food by exercise have produced contradictory 
results. In an attempt to determine the extent to which 
exercise enhances the thermic effect of food, one study 
examined the response of weight-stable lean and obese 
women to food and two levels of exercise: (1) the same 
absolute level for all women and (2) a level related to 
each woman’s aerobic fitness. 29 The key finding of this 
study was that exercise potentiated the thermic effect of 
food for the lean women but not for the obese women 
despite the fact that similar thermogenic responses were 
observed to food alone and to exercise alone in both 
groups. The thermic effect was 2.54 times greater during 
exercise than at rest for those in the lean group but only 
1.01 times greater for those who were obese. Although 
several investigators have shown that the effect of exer- 
cise on the thermic response to meals is potentiated, the 
effect is moderate. This may have long-term significance, 
however, for increased total energy expenditure. The 
potentiation may be defective in obese individuals. 19 

Behavioral Modification 

Approximately 20 years ago, the behavioral approach 
to the treatment of obesity attracted much attention and 
stimulated considerable research and clinical application 
of this hypothesis. The rationale for this approach is that 
major changes in eating and exercise behaviors are 
necessary to ensure long-term weight control and that 
this must be preceded by a thorough analysis of eating 
and activity patterns. 

Six core characteristics are associated with behavioral 
therapy: 30 (1) an assumption that all behavior is acquired 
and maintained according to definable principles; (2) a 
belief that people are best described by their behavior — 
what they think, feel, and do in specific situations; (3) an 
attempt to specify treatment measures as precisely as 
possible and to evaluate outcomes as objectively as pos- 
sible; (4) an effort to individualize treatment; (5) nego- 
tiation of treatment goals between patient and therapist; 
and (6) continuing and critical assessment of the treat- 
ment throughout its course. 



Behavioral assessment of obese persons involves 
attention to (1) the antecedents of eating that promote 
excessive intake (eg, separating eating from other activi- 
ties, such as watching television; limiting the amount and 
accessibility of high-energy foods); (2) slowing the act of 
eating; and (3) selectively emphasizing the consequences 
of certain behaviors (eg, rewarding appropriate eating 
behaviors). 31 

Some studies suggest that behavior therapy is effective 
for patients who need to lose moderate amounts of 
weight and to maintain these weight losses for at least 
one year. 30 In comparing effects of behavioral and 
pharmacologic therapy in obese subjects, patients receiv- 
ing drugs lost significantly more weight during the 
treatment phase, but patients who received behavioral 
therapy were more successful in maintaining their weight 
losses. 30 Thus, for better maintenance of weight loss, it 
appears that behavioral therapy is superior to short-term 

A majority of studies on behavioral treatment of obes- 
ity do not include long-term follow-up data. The findings 
of a five-year follow-up of 36 individuals who partici- 
pated in a behavioral program for obesity showed a 
typical pattern of regaining all the weight lost during 
treatment. 32 New approaches that foster maintenance of 
weight reduction are receiving attention, eg, relapse 
prevention training, utilization of social support systems, 
posttreatment contacts with the therapist. It appears that 
appropriate behavioral strategies during the posttreat- 
ment stage can form the basis for lasting weight control. 

The benefits of behavior modification may be enhanced 
when such treatment is combined with other forms of 
therapy, such as diet and exercise. 

Evaluating Commercial Weight-Loss Clinics 

Resolution 59, 1983 Annual Meeting, stated, “Any 
person considering participation in a weight loss pro- 
gram offered by a weight loss clinic should first consult 
his regular attending physician, or any other indepen- 
dent physician, for a physical examination and an objec- 
tive professional evaluation of the proposed weight loss 
program as it relates to the individual’s physical 

One of the essential factors to consider in evaluating a 
weight-loss clinic is whether treatment is preceded by 
careful medical and behavioral assessment. Assessment 
of baseline eating and exercise behavior is important to 
determine if the weight problem is due to overeating 
and/or lack of exercise. 33 Some clinics emphasize only 
restriction of energy intake. 

The degree of obesity should determine the approach 
to be used for each individual. No one form of treatment 
is suitable for all obese individuals. Those who require 
stringent diets, such as the protein-sparing modified fast, 
should be supervised by physicians who have knowledge 
of the metabolic consequences of the regimen. 

The relationship between the patient and the therapist 
should be of sufficiently long duration to effect appro- 
priate changes in the patient’s life-style, which may 

require treatment for a year or more; unfortunately, 
most patients do not participate in commercial programs 
long enough for this to occur. 33 

The most important consideration in evaluating a 
weight-loss clinic is the outcome. The probability of a 
successful outcome can be determined only if informa- 
tion is obtained on the average dropout rate, average 
posttreatment weight loss, and weight maintenance for 
one year following treatment. Other factors, such as cost 
and quality of treatment, should be discussed by the 
physician and the patient before a decision is made to 
utilize the services of a weight-reduction clinic. 33 
Guidelines For Therapeutic Weight-Control Programs 

Relatively little information is available in the medical 
literature to support very specific recommendations in 
this area. However, a panel organized under the auspices 
of the Fourth International Congress on Obesity de- 
scribed the minimum recommended features of a profes- 
sional weight-control program combining diet, exercise, 
and behavioral and psychological therapy. 34 The guide- 
lines are summarized briefly in this section. 

Diet Therapy 

Dietary recommendations should be individualized to 
meet the patient’s needs and habits and should be devel- 
oped through close interaction of patient and therapist. 
The diet should have the following characteristics: (1) a 
sound scientific rationale; (2) safety, nutritional ade- 
quacy (ie, an acceptably low risk:benefit ratio), and satis- 
faction of all nutrient needs except energy; and (3) prac- 
ticality and long-term effectiveness (ie, the diet should be 
both practical for and applicable to the patient’s envi- 
ronment, and it should be conducive to weight main- 

Exercise Therapy 

As part of a weight-control program, the exercise 
component should ( 1 ) promote increased energy expen- 
diture, (2) promote fat loss and maintenance of lean 
body mass, (3) be safe for the participating individuals, 
and (4) promote increases in activity levels within the 
individual’s life-style. 

Behavioral and Psychological Assessment 

Treatment should focus on methods of acquiring new 
behaviors that will promote weight loss and long-term 
maintenance of weight loss. An individual preliminary 
interview should precede therapy to rule out factors that 
would preclude successful response to therapy. Certain 
therapeutic modalities should be included, such as record- 
keeping of food choices and activity patterns, stimulus 
control (ie, attention to antecedents of eating that pro- 
mote excessive intake) and modification of eating behav- 
ior, cognitive restructuring, and utilization of social sup- 
port systems. 

Approaches that foster weight maintenance should be 
included during the posttreatment period (eg, resump- 
tion of daily monitoring of dietary and physical activity 
patterns if weight gain occurs). Once weight is stabilized, 
long-term follow-up should include annual evaluation. 

VOLUME 53, NO. 1 


If weight loss is to be maintained, major changes in 
life-styles are required. Gradual changes in eating habits 
and exercise levels must take place, and psychological 
factors that impinge on these components must be ad- 
dressed. Such changes can occur only in a comprehen- 
sive weight-reduction program, the only effective treat- 
ment for obesity. 35 


Three essential components of a weight-control pro- 
gram are diet, exercise, and behavior modification. Be- 
cause these elements are interdependent and mutually 
supportive, a program that incorporates all three is more 
likely to lead to long-term weight control. 

In evaluating commercial weight-loss clinics, it should 
be ascertained that the proposed weight-loss program is 
appropriate for the individual’s physical condition and 
that proper medical supervision is provided at the clinic 
by physicians who have knowledge of the metabolic 
consequences of the prescribed regimen. An important 
consideration is a successful outcome, which can be 
assessed by obtaining information on the average drop- 
out rate, average posttreatment weight loss, and weight 
maintenance for at least one year following treatment. 

For weight loss to be maintained, gradual changes in 
eating habits and exercise levels must occur and psycho- 
logical factors that impinge on these components must 
be addressed. A comprehensive, long-term weight-con- 
trol program is the only effective treatment for obesity. 


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human obesity. TV Engl J Med 1986;314:193-8. 

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12. Drenick EJ, Johnson D: Weight reduction by fasting and 
semistarvation in morbid obesity: Long-term follow-up, in Bray 
GA (ed ):Obesity: Comparative Methods of Weight Control. 
Westport, Conn. Technomic Publishing Co Inc., 1980, pp 25-34. 

13. Newmark SR, Williamson B: Survey of very-low-calorie weight 
reduction diets: II. Total fasting, protein-sparing modified fasts, 
chemically defined diets. Arch Intern Med 1983;143:1423-7. 

14. Felig PL: Very-low-calorie protein diets. TV Engl J Med 1984; 

15. Wadden TA, Stunkard AJ, Brownell KD, et al: A comparison of 
two very-low-calorie diets: Protein-sparing-modified fast vs pro- 
tein-formula-liquid diet. Am J Clin Nutr 1985;41:533-9. 

16. Wadden TA, Stunkard AJ, Brownell KD: Very low calorie diets: 
Their efficacy, safety, and future. Ann Intern Med 1983; 99:675-84. 

17. Dwyer J: Classifying current popular and fad diets, in Hirsh J, Van 
Itallie TB (eds): Recent Advances in Obesity Research: IV. Lon- 
don, John Libbey & Co Ltd, 1985, pp 179-91. 

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supplements and as therapeutic agents. JAMA 1987;257: 1929-36. 

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Methods of Weight Control. Westport, Conn. Technomic Pub- 
lishing Co Inc, 1980, pp 15-24. 

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reduction diets: I. Novelty diets. Arch Intern Med 1983; 143:1 195-8. 

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obesity, in White PL, Mondieka TD (eds): Diet and Exercise: 
Synergism in Health Maintenance. Chicago, American Medical 
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22. Ravussin E, Burnard B, Schutz Y, et al: Energy expenditure before 
and during energy restriction in obese patients. Am J Clin Nutr 

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consequences of dieting and exercise in the treatment of obesity. J 
Consult Clin Psychol 1984;52:827-36. 

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obesity: Metabolic consequences, in Frankie RT, Dwyer J, 
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Obesity. London, John Libbey & Co Ltd, 1985, pp 1 1-19. 

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taneous calorie intake in obesity. Am J Clin Nutr 1982;36:470-7. 

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obesity, in Frankie RT, Dwyer J, Moragne L, et al (eds): Dietary 
Treatment and Prevention of Obesity. London, John Libbey & Co 
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approach to outpatient obesity management. J Am Diet Assoc 




Urinary Incontinence in Adults 


U RINARY incontinence, the involuntary loss of 
urine so severe as to have social and/or hygienic 
consequences, is a major clinical problem and a signifi- 
cant cause of disability and dependency. Urinary incon- 
tinence affects all age groups and is particularly common 
in the elderly. At lease 10 million adult Americans suffer 
from urinary incontinence, including approximately 
15% to 30% of community-dwelling older people and at 
least one-half of all nursing home residents. The mone- 
tary costs of managing urinary incontinence are conser- 
vatively estimated at $10.3 billion annually, and the 
psychosocial burden of urinary incontinence is great. 

Urinary incontinence is a symptom rather than a dis- 
ease. It appears in a limited number of clinical patterns, 
each having several possible causes. In some cases, the 
disorder is transient, secondary to an easily reversed 
cause such as a medication or an acute illness like urinary 
tract infection. Many cases are chronic, however, lasting 
indefinitely unless properly diagnosed and treated. 

There is a persistent myth that urinary incontinence is 
a normal consequence of aging. While normal aging is 
not a cause of urinary incontinence, age-related changes 
in lower urinary tract function predispose the older per- 
son to urinary incontinence in the face of additional 
anatomic or physiologic insults to the lower urinary tract 
or by systemic disturbances such as illnesses common in 
older people. 

Even frail nursing home residents or persons being 
cared for by family caregivers often have urinary incon- 
tinence that can be significantly improved or cured. Per- 
sons with urinary incontinence should be alerted to the 
importance of reporting their symptoms to a health care 
professional and of asserting their right to proper assess- 
ment, diagnosis, and treatment. The first steps to treat- 
ment are acknowledgment of the problem and appro- 
priate assessment and diagnosis. 

Knowledge of the occurrence, causes, consequences, 
and treatment of the specific forms of urinary inconti- 
nence has increased. While new diagnostic tests have 
been developed, well-defined guidelines are needed for 
their application. Similarly, despite numerous new po- 

From the Office of Medical Application of Research, National 
Institutes of Health, Bethesda, MD. 

Reprint requests to the Office of Medical Applications of Research, 
Room 216, National Institutes of Health, Bethesda, MD 20205. 

tential therapies, opinions differ widely concerning the 
best approach to many specific forms of the disorder. 
The most common treatments include pelvic muscle 
exercises and other behavioral treatments, local and sys- 
temic drug therapies, and a variety of surgical 

The number of patients with urinary incontinence 
who are not successfully treated remains surprisingly 
high. This is due to several factors, including underre- 
porting by patients; underrecognition as a significant 
clinical problem by health providers; lack of education of 
health providers regarding new research findings; inade- 
quate staffing in the long-term care setting; and the 
persistent major gaps in our understanding of the natural 
history, pathophysiology, and most effective treatments 
of the common forms of urinary incontinence. The 
amount of basic research as well as research focusing on 
prevention is meager. 

To resolve issues regarding the incidence, causes, treat- 
ment, and consequences of urinary incontinence in 
adults, the National Institute on Aging and the Office of 
Medical Applications of Research of the National Insti- 
tutes of Health, in conjunction with the National Insti- 
tute of Diabetes and Digestive and Kidney Diseases, the 
National Center for Nursing Research, the National 
Institute of Neurological and Communicative Disorders 
and Stroke, and the Veterans Administration, convened 
a Consensus Development Conference on Urinary In- 
continence in Adults on 3-5 October 1988. After a day 
and a half of presentations by experts in the relevant 
fields involved with urinary incontinence, a consensus 
panel consisting of representatives from geriatrics, urol- 
ogy, gynecology, psychology, nursing, epidemiology, 
basic sciences, and the public considered the evidence 
and developed answers to the following central ques- 

• What is the prevalence and clinical, psychological, and 
social impact of urinary incontinence among persons 
living at home and in institutions? 

• What are the pathophysiological and functional fac- 
tors leading to urinary incontinence? 

• What diagnostic information should be obtained in 
assessment of the incontinent patient? What criteria 
should be employed to determine which tests are 
indicated for a particular patient? 

VOLUME 53, NO. 1 


• What are the efficacies and limitations of behavioral, 
pharmacological, surgical, and other treatments for 
urinary incontinence? What sequences and/or com- 
bination of these interventions are appropriate? What 
management techniques are appropriate when treat- 
ment is not effective or indicated? 

• What strategies are effective in improving public and 
professional knowledge about urinary incontinence? 

• What are the needs for future research related to 
urinary incontinence? 

1. What is the prevalence and clinical, psychological, 
and social impact of urinary incontinence among 
persons living at home and in institutions? 

A. Occurence and Risk 

Estimates of the occurrence of urinary incontinence 
depend on the nature of the study population and defini- 
tion of the disorder. Prevalence rates range from 8% to 
5 1 %; an estimate of 1 5% to 30% for community-dwelling 
older persons seems reasonable, and of these, 20% to 
25% may be classified as severe. Prevalence rates are 
twice as high in women as in men, and are higher in older 
than in younger adults. Though these community rates 
are alarmingly high, rates in nursing homes are even 
higher. Half or more of the 1.5 million Americans in 
nursing homes suffer from urinary incontinence. 

Little is known about the natural history of urinary 
incontinence, including age at onset, incidence rates, 
progression, and spontaneous remission. Limited data 
exist on associated morbidity and functional impair- 
ment. To date, most studies have been conducted in 
whites, and data are needed on the occurrence in non- 
white ethnic groups. 

Though urinary incontinence is a symptom of many 
conditions, defining risk factors would be extremely use- 
ful for identifying high-risk persons and remediable 
environmental causes. While age, gender, and parity are 
established risk factors, many other factors have been 
suggested but not rigorously proven. These include uri- 
nary tract infection, menopause, genitourinary surgery, 
lack of postpartum exercise, chronic illnesses, and var- 
ious medications. Risk factor identification is essential 
for a concerted effort at prevention. 

B. Clinical, Psychological, and Social Impact 
In the Community 

Because only about half of the people with inconti- 
nence in the community have consulted a doctor about 
the problem, the true extent and clinical impact of uri- 
nary incontinence is not known. Rashes, pressure sores, 
skin and urinary tract infections, and restriction of activ- 
ity are some of the problems that could be prevented or 
treated if the underlying incontinence were brought to 
medical attention. Many people with incontinence turn 
prematurely to the use of absorbent materials without 
having their difficulty properly diagnosed and treated. 

The psychosocial impact of incontinence in the com- 
munity falls on individuals and their care providers. 
Studies of women show that the condition is associated 
with depressive symptoms and leads to embarrassment 
about appearance and odor, although such reactions 

may be related more to illness than to incontinence. 
Excursions outside the home, social interactions with 
friends and family, and sexual activity may be restricted 
or avoided entirely in the presence of incontinence. 
Spouses and other intimates also may share the burden 
of this condition. A highly conservative estimate of the 
direct costs of caring for persons with incontinence of all 
ages in the community is $7 billion annually in the 
United States. 

In Nursing Homes 

Many physicians fail to recognize the clinical impact 
of urinary incontinence in nursing homes, and very few 
nursing home residents with incontinence have had any 
type of diagnostic evaluation. In this setting, fecal incon- 
tinence, physical and mental impairment, pressure sores, 
and urinary tract infections are commonly associated 
with urinary incontinence, but cause-and-effect relation- 
ships are not clear. Many nursing home residents who 
are incontinent are managed with indwelling catheters, 
which carry an increased risk of significant urinary tract 
infection, and the use of such devices varies widely. The 
odor of urine that permeates many nursing homes can be 
repellent to residents, staff, and potential visitors. Man- 
aging those with incontinence presents a major problem 
to insufficient and often untrained staff. The annual 
direct cost of caring for incontinence among nursing 
home patients is approximately $3.3 billion. 

2. What are the pathophysiological and functional fac- 
tors leading to urinary incontinence? 

Continence requires a compliant bladder and active 
sphincteric mechanisms, but that maximum urethral 
pressure always exceeds intravesical pressure. Normal 
voiding requires sustained and coordinated relaxation of 
the sphincters and contraction of the urinary bladder. 

These functions are regulated by the central nervous 
system through autonomic and somatic nerves. The sys- 
tem requires the integration of visceral and somatic mus- 
cle function and involves control by voluntary mechan- 
isms originating in the cerebral cortex. These voluntary 
mechanisms are learned and culturally prescribed (ie, 
toilet training). 

Incontinence can be produced by any pathologic, ana- 
tomic, or physiologic factor that causes intravesical pres- 
sure to exceed maximum urethral pressure. Intravesical 
pressure can be raised by involuntary detrusor contrac- 
tions (unstable bladder or detrusor hyperreflexia), by 
acute or chronic bladder overdistension (urinary reten- 
tion with overflow), or by an increase in intra-abdominal 
pressure. Similarly, a decrease in urethral pressure may 
occur as a result of uninhibited sphincter relaxation 
(unstable urethra), loss of pelvic tloor support (genuine 
stress incontinence), and urethral wall defects from 
trauma, surgery, or neurologic disease. 

Subtypes of Urinary Incontinence 

The most commonly encountered clinical forms of 
urinary incontinence in adults are stress incontinence, 
urge incontinence, overflow incontinence, and a mixed 
form. In stress incontinence, dysfunction of the bladder 
outlet leads to leakage of urine as intra-abdominal pres- 



sure is raised above urethral resistance while coughing, 
bending, or lifting heavy objects. Volume of urine leak- 
age is generally modest at each occurrence and, in 
uncomplicated cases, postvoid residual volume is low. 
Stress incontinence has many causes, including direct 
anatomic damage to the urethral sphincter (sphincteric 
incontinence), which may lead to severe, continuous 
leakage, and weakening of bladder neck supports, as is 
often associated with parity. 

Urge incontinence occurs when patients sense the urge 
to void (urgency) but are unable to inhibit leakage long 
enough to reach the toilet. In most, but not all, cases, 
uninhibited bladder contractions contribute to the in- 
continence. Urine loss is moderate in volume, occurs at 
several hour intervals, and postvoid residual volume is 
low at several hour intervals. Among the causes of urge 
incontinence are central nervous system lesions such as 
stroke or demyelinating disease, which impair inhibition 
of bladder contraction, and local irritating factors such 
as urinary infection or bladder tumors. In many cases of 
urge incontinence, no specific etiology can be identified 
despite detailed clinical and laboratory evaluation. 

An important variant of urge incontinence is reflex 
incontinence, in which urine is lost due to uninhibited 
bladder contractions in the absence of the symptoms of 
urgency. In addition, many persons suffer from very 
frequent symptoms of urgency and are only able to 
remain continent by conducting their activities in the 
proximity of restrooms. 

Overflow incontinence occurs when the bladder can- 
not empty normally and becomes overdistended, leading 
to freqent, sometimes nearly constant, urine loss. Causes 
include neurologic abnormalities that impair detrusor 
contractile capacity, including spinal cord lesions, and 
any factor that obstructs outflow, including medications, 
tumors, benign strictures, and prostatic hypertrophy. 

Many cases of urinary incontinence fall into the mixed 
category, displaying some aspects of more than one of 
the major subtypes, both clinically and on extensive 
laboratory evaluation. 

The term “functional” incontinence is applied to those 
cases in which the function of the lower urinary tract is 
intact, but other factors such as immobility or severe 
cognitive impairment result in urinary incontinence. 

It should be clear that urinary incontinence can be 
caused by multiple and often interacting conditions. Of 
particular importance are the transient or reversible fac- 
tors such as infection, delirium, and drugs. These causes, 
which may be common in the elderly patient, should be 
carefully considered in the pathophysiology of urinary 

There are age-related changes in the lower urinary 
tract that increase its vulnerability to both chronic and 
transient factors. Increases in uninhibited contractions, 
nocturnal fluid excretion, and prostate size, accompan- 
ied by decreases in bladder capacity and flow rate, all 
lead to greater susceptibility to urinary incontinence in 
the face of stresses associated with disease, functional 
impairment, or environmental factors. In older persons, 

cognitive decline, musculoskeletal impairments, and re- 
stricted access to toilets may all convert the marginally 
continent system to incontinence. 

3. What diagnostic information should be obtained in 
assessment of the incontinent patient? What criteria 
should be employed to determine which tests are 
indicated for a particular patient? 

Evaluation and therapy must be tailored to the indi- 
vidual, taking into account clinical, cognitive, function- 
al, and residential status in addition to the potential for 
correcting the problem. Just as a child is not simply a 
young adult, octogenarians differ from persons in their 
forties. Patients with stress urinary incontinence are 
quite dissimilar from those with uninhibited contrac- 
tions and unstable bladders. Proper diagnosis and active 
case finding are imperative. 

Core Evaluation 

The evaluation of all patients with incontinence re- 
quires a thorough history, including medical, urologic, 
gynecologic, and neurologic assessment, with particular 
attention to those factors that influence bladder func- 
tion. The duration, frequency, volume, and type of 
incontinence should be described and validated by a 
voiding diary. Other important information includes 
associated illnesses, previous operations, and current 

Physical Examination 

Physical examination is required, with emphasis on 
mental status; mobility and dexterity; and neurologic, 
abdominal, rectal, and pelvic findings. A provoked full- 
bladder stress test is recommended. Since prostate en- 
largement is often asymmetric, the size of the prostate as 
estimated on rectal exam may be misleading when eval- 
uating the possible contribution of prostatic hypertro- 
phy to urinary obstruction. 

In addition to the history and physical examination, 
core measurements to be obtained in all patients are 
urinalysis, serum creatinine or blood urea nitrogen, and 
postvoid residual urine volume. Other tests such as urine 
culture, blood glucose, and urinary cytology may be 

Based on the findings from the core evaluation, a 
decision for treatment or more definitive evaluation is 
made, taking into consideration the type and degree of 

Specialized Studies 

The tests currently available for specialized study 

• Cystometrogram — to be used as the basic study in 
cases requiring more than core evaluation, should be 
accompanied by measurement or estimation of ab- 
dominal pressure. 

• Electrophysiologic sphincter testing (EMG). 

• Ultrasound of the bladder or kidneys may detect 
residual urine or hydronephrosis. 

• Cystourethroscopy with or without cytology is indi- 
cated in patients with hematuria or the recent onset of 

VOLUME 53, NO. 1 


urgency or urge incontinence who are at increased 
risk for carcinoma. 

• Uroflowmetry has wide application in the evaluation 
of obstructive disease in men but a limited role in the 
evaluation of women. 

• Videourodynamic evaluation requires special exper- 
tise. Its role is limited to the more elusive incontinence 

• Urethral pressure profllometry is a controversial test. 
Its predictive value has been questioned, and it re- 
quires further validation before it can be recommend- 
ed for widespread use. 

These numerous noninvasive and invasive tests must 
be used selectively. Examples of patients rarely requiring 
further diagnostic testing after the core examination 
include the young woman with classic stress incontinence 
or the 80-year-old woman with a recent stroke and the 
new onset of urge incontinence. Patients with stress 
incontinence and a significant urge component or those 
in whom previous operations have failed may require 
combined cystography and fluoroscopy with a complete 
urodynamic evaluation. Some patients with urge or 
mixed incontinence, or those who are not helped by 
empiric therapy or operation, also will require more 
complete urodynamic testing. Some patients may not be 
candidates for sophisticated studies due to inability to 
cooperate or a poor prognosis for correction. Armed 
with this information, the investigating physician should 
be able to reach an accurate diagnosis leading to appro- 
priate therapy. 

4. What are the efficacies and limitations of behavioral, 
pharmacological, surgical, and other treatments for 
urinary incontinence? What sequences and/or com- 
bination of these interventions are appropriate? What 
management techniques are appropriate when treat- 
ment is not effective or indicated? 

A. General Principles of Treatment 

• All persons with incontinence should be considered 
for evaluation and treatment. 

• Treatment decisions should be based on a diagnosis 
made after a reasonable evaluation of anatomy and 
function of urine storage and emptying. 

• Treatment for incontinence is given to a specific indi- 
vidual, whose personality, environment, expectations, 
and clinical status are important determinants of 
treatment modalities to be used and the order of their 

• The patient requires sufficient information and explan- 
ation to be able to make a choice among therapeutic 

• Environmental constraints in the community or in an 
institution that may impede treatment are common, 
and strategies to circumvent impediments are a part 
of the therapy. 

• In particular, availability of adequate numbers of 
properly constructed public toilets is an important 
adjunct to incontinence management. 

B. Pharmacologic Treatment 

Most drugs currently used in managing the varied 

causes of urinary incontinence have not been studied in 
well-designed clinical trials. Nevertheless, it has been 
suggested that many agents are beneficial, especially for 
urge incontinence due to uninhibited detrusor contrac- 
tions. For these patients, drugs that increase bladder 
capacity can be helpful. One attendant risk is the precipi- 
tation of retention. Accordingly, outlet obstruction or a 
weak detrusor should be looked for as possible contrain- 
dications to these agents. 

Bladder Relaxants 

These agents are generally used for urge incontinence: 

• Anticholinergics 

Anticholinergic agents inhibit detrusor contraction, 
and may produce increased bladder capacity and delay 
and reduction in amplitude of involuntary contractions. 
Propantheline is frequently effective, although high doses 
may produce unacceptable side effects such as dry mouth, 
dry eyes, constipation, confusion, or precipitation of 

• Direct Smooth Muscle Relaxants 

These antispasmodics work directly on bladder mus- 
cle, but they have a mild anticholinergic effect as well. A 
randomized, double-blind, placebo-controlled study has 
shown benefit with oxybutynin in patients with detrusor 
instability, some but not all of whom were incontinent. 
Favorable reports also exist about flavoxate and dicy- 
clomine, the other two agents in this class. 

• Calcium Channel Blockers 

These agents, used clinically for cardiovascular indica- 
tions, have a depressant effect on the bladder as well, but 
they have not been studied rigorously for the treatment 
of urge incontinence in comparison with other agents. In 
the patient being considered for treatment for heart dis- 
ease, the bladder effects of calcium antagonists must be 
kept in mind for both their potential benefit as well as 
risk of retention. 

• Imipramine 

This tricyclic antidepressant has anticholinergic and 
direct relaxant effects on the detrusor and an alpha 
adrenergic enhancing (contracting) effect on the bladder 
outlet, all of which enhance continence. Although im- 
ipramine is commonly used, potential side effects of 
postural hypotension and sedation as well as all peripher- 
al anticholinergic effects make caution imperative when 
considering this agent in older persons. 

Bladder Outlet Stimulants 

Alpha adrenergic agonists, used in treatment of stress 
incontinence, produce smooth muscle contraction at the 
bladder outlet and may improve continence. Pseudo- 
ephedrine and ephedrine both are active, but phenyl- 
propanolamine has been used most often, and objective 
benefit by urodynamic study has been shown. 


Because urinary incontinence increases in women with 
increasing age, and because menopause results in estro- 
gen deficiency, estrogen replacement has been 
thought to be helpful for urinary incontinence. Several 
studies have shown no improvement in stress inconti- 



nence, but women with postmenopausal urge inconti- 
nence, urgency, and frequency have shown improve- 
ment. Long-term use should be considered in view of 
other risks and benefits. 

C. Surgery 

Surgery is particularly effective in treatment of pure 
stress incontinence associated with urethrocoele. A var- 
iety of surgical techniques for the transvaginal or trans- 
abdominal suspension of the bladder neck yield a success 
rate between 80% and 95% in appropriately selected 
patients with stress incontinence at one-year follow-up. 
Long-term results require study. When incontinence in 
men is secondary to outflow obstruction and chronic 
retention is secondary to prostatic enlargement, it is best 
treated with prostatectomy. 

In addition, there are several specialized and more 
extensive surgical procedures. When incontinence is due 
to intrinsic sphincter dysfunction, which may occur after 
the surgical trauma of radical prostatectomy or sphincter 
denervation, the compression action of the sphincter is 
lost. An implantable prosthetic sphincter can restore this 
compression. Continence is restored in 70% to 90% of 
patients in various series. A complication rate greater 
than 20% includes erosion of the urethra, infection, and 
mechanical failure. Reoperations are frequently required. 

Urethral sling procedures pass a ribbon of fascia or 
artificial material beneath the urethra. The sling, fixed 
to the anterior body wall, serves to elevate and compress 
the urethra, restoring continence in 80 % of patients. 
Bladder augmentation with isolated bowel segments 
will increase bladder capacity and vent excessive bladder 
pressure. This procedure is limited to certain specific 
bladder problems such as the contracted bladder of 
neurologic disease or tuberculosis. Bladder replacement 
with continent diversion can also be offered to the cys- 
tectomy patient. 

There are no simple procedures to control bladder 
instability or sensory urgency. When incontinence is due 
to a mixture of stress and urge, pharmacologic or behav- 
ioral treatment may be employed in conjunction with 
surgery, but results are not as good as when stress incon- 
tinence exists alone. 

Selection of patients for surgical procedures depends 
upon the diagnosis and upon the condition of the patient. 
The frailty of the patient, the condition of tissues, and the 
state of nutrition bear on the ability to heal. The severity 
of symptoms must be considered in relation to the risk 
the patients must undertake for their surgical correction. 
Finally, such factors as the durability of the treatment 
and the incidence of complications must also be consid- 
ered in choosing a treatment option. 

D. Behavioral Techniques 

Behavioral techniques increase the patient’s awareness 
of the lower urinary tract and environment and can 
enhance control of detrusor and pelvic muscular func- 
tion. Such techniques are participatory, relatively nonin- 
vasive, and generally free of side effects, and they do not 
limit future options. They do require time, effort, and 
continued practice. Some patients become dry, while a 

larger number experience important reduction of wet- 
ness, and others receive no benefit. Those who appear to 
benefit are highly motivated individuals without cogni- 
tive deficits. Men and women with stress and urge incon- 
tinence have benefited, whereas patients with severe 
sphincter damage (such as in postradical prostatectomy 
with constant leakage) generally do not benefit. 

Behavioral techniques should be offered as a choice to 
patients who are motivated to put in the time and effort 
and wish to avoid a more invasive procedure. Com- 
monly employed techniques include: 

• Pelvic muscle exercises strengthen the voluntary peri- 
urethral and pelvic floor muscles, the contraction of 
which exerts a closing force on the urethra. These 
techniques have been emphasized for women with 
stress incontinence but appear to be useful in men as 
well. Benefit has been reported in 30% to 90% of 
women, but criteria for improvement differ among 
studies. Patients with mild symptoms may improve 
most. Continued exercise is required for continued 

• Biofeedback is a learning technique to exert better 
voluntary control over urine storage. Biofeedback 
uses visual or auditory instrumentation to give patients 
moment to moment information on how well they are 
controlling the sphincter, detrusor, and abdominal 
muscles. After such training, successful patients typi- 
cally learn to perform the correct responses relatively 
automatically. Patients with urinary incontinence are 
trained to relax the detrusor and abdominal muscles 
and/or contract the sphincter, depending upon the 
form of incontinence. When used in patients with 
stress and / or urge incontinence, biofeedback has been 
shown to result in complete control of incontinence in 
approximately 20% to 25% of patients and to provide 
important improvement in another 30%. There are 
two caveats: the degree of improvement is variable, 
and long-term follow-up data are not available. It is 
important to recognize that biofeedback requires 
sophisticated equipment and training. The benefit of 
adding biofeedback to pelvic muscle exercise regi- 
mens has not been adequately evaluated. 

• Bladder Training instructs patients to void at regular 
short intervals, usually hourly during the day, and 
then at progressively longer intervals of up to 3 hours 
over a training period of a few to a dozen weeks. 
Bladder training appears to be effective in reducing 
the frequency of stress and urge incontinence. Studies 
have indicated cure rates of 10% to 15% and im- 
provement in the majority of patients. 

• Behavioral techniques in the nursing home. For insti- 
tutionalized elderly, almost any consistent attention 
to the problem, including bladder training and fre- 
quent scheduled checks for dryness appears to reduce 
incontinence in at least some patients. Another tech- 
nique applicable in the nursing home is prompted 
voiding, in which frequent (one to two hourly) checks 
for dryness are made, reminding the patient to void 
and praising success. 

VOLUME 53, NO. 1 


E. Staging of Treatment 

As a general rule, the least invasive or dangerous 
procedures should be tried first. For many forms of 
incontinence, behavioral techniques meet this criterion. 
When behavioral techniques do not achieve the desired 
result, pharmacologic treatment can be initiated. Clear 
indications for surgical intervention must be respected, 
however, and surgical treatment should not be withheld 
inappropriately. Overflow incontinence due to prosta- 
tism and urge incontinence due to carcinoma of the 
bladder or prostate must be recognized and treated 
promptly. After having been informed of surgical and 
nonoperative options, the patient who is a surgical can- 
didate and wants prompt treatment (eg, as in the case of 
stress incontinence) should be operated on. In patients 
with mixed incontinence, a combination of surgery, 
behavioral techniques and pharmacotherapy may be 

F. What management techniques are appropriate when 

treatment is not effective or indicated? 

For patients who have not been successfully treated, 
management plans must be developed to maximize their 
well-being. Even when permanent improvement is not 
expected, techniques such as frequent toileting and re- 
minders may be useful in reducing the impact of the 
patient’s incontinence. Careful evaluation of the timing 
and pattern of incontinence may suggest helpful changes 
such as bedtime fluid restriction, provision of easier 
access to toilet facilities, and temporary or permanent 
arrangements for protection of the patients, their cloth- 
ing, and environment. 

Currently available modes of protection include ab- 
sorbent pads or garments, indwelling catheters, and 
external collection devices such as condom catheters. 
Absorbent pads or garments provide comfort and con- 
venience when used temporarily in conjunction with 
therapy; no method is entirely satisfactory for long-term 
use. For long-term use with incapacitated patients, ab- 
sorbent materials are expensive, require personnel time, 
and can be associated with pressure sores when circum- 
stances prevent meticulous attention to prompt changes. 

For men, external collection devices are less expensive 
and less time-consuming for patient and caregiver, but 
they are associated with increased incidence of urinary 
tract infection and other complications. Practical exter- 
nal collection devices for women are not generally 

Indwelling urethral or suprapubic catheters may be 
necessary for selected patients, but almost invariably 
lead to bacteriuria within a few weeks and have been 
associated with sepsis. 

5. What strategies are effective in improving public and 

professional knowledge about urinary incontinence? 

There have been limited efforts to inform the public 
and professionals about urinary incontinence. The effec- 
tiveness of these strategies has not been evaluated. Incon- 
tinence education, therefore, must rely on methods that 
have been used in other areas of health education. Effec- 
tive strategies to improve public and professional aware- 
ness need to be developed, implemented, and evaluated. 

Negative societal attitudes about urinary incontinence 
have been a barrier to increasing public and professional 
knowledge. The scientific study of incontinence and the 
dissemination of research findings will help professionals 
and laypersons realize that loss of continence need not be 
a condition that is inevitable or shameful. 

Strategies for Improving Public Knowledge 

Providing accurate information on the management 
of incontinence to persons with this problem and their 
families is a challenging and important task. Studies 
suggest that only half of the people with incontinence 
report their condition to a physician. Strategies that will 
reach the largest number of people will be effective in 
encouraging them to seek professional help. These in- 
clude informative newspaper and magazine articles, radio 
and television programs, and special education programs 
in senior centers. 

One innovative suggestion that deserves consideration 
is the mandatory labeling of all absorbent products, 
informing the public that persistent urinary incontinence 
should be evaluated and that effective treatments are 

Strategies for Improving Professional Knowledge 

There is an urgent need to educate professionals and 
paraprofessionals about urinary incontinence. 

First and foremost, information on urinary inconti- 
nence should be included in the core curricula of under- 
graduate and graduate professional schools. Schools of 
nursing should consider the feasibility of educating spe- 
cialists on incontinence care, who can serve as expert 
advisers to health care professionals. 

To increase practitioners’ knowledge of this important 
condition, continuing education courses focusing on the 
types of incontinence and appropriate diagnostic mea- 
sures and treatment should be offered. Professionals 
most likely to provide care to people with incontinence 
should be encouraged to attend these courses. 

Education on the topic of urinary incontinence should 
also be a part of the training programs for para- 
professional students such as licensed vocational nurses, 
nurses aides, and auxiliary workers in the community. 
Because urinary incontinence is a problem of great mag- 
nitude in long-term care settings, special emphasis should 
be placed on educating nurses aides. 

Last, coordinated care for people with incontinence 
will be facilitated by encouraging alliances among all 
professionals responsible for caring for people with in- 

6. What are the needs for future research related to 
urinary incontinence? 

The Consensus Development Conference on Urinary 
Incontinence in Adults has provided an overview of 
current knowledge on the etiology, pathophysiology, 
sequelae, and management of this prevalent clinical 
problem. Although information on incontinence is in- 
creasing, this field has long been neglected, and numer- 
ous gaps exist in our knowledge. While many controver- 
sies were addressed, numerous questions were identified 



that await answers and thus serve as the focus for future 
research directions. These issues will require the collab- 
orative input of investigators from the spectrum of rele- 
vant disciplines and the rigorous application of ap- 
propriate research principles. 

Directions for future research: 

• Basic research on the mechanisms underlying the eti- 
ology, exacerbation and response to treatment of 
specific forms of urinary incontinence and urgency. 

• Epidemiologic studies with emphasis on elucidation of 
risk factors for development of urinary incontinence, 
its occurrence in specific populations (particularly 
males and nonwhites), and the natural history of the 
various clinical and physiologic subtypes. 

• Studies of strategies to prevent urinary incontinence. 

• Randomized clinical trials, including longitudinal 
studies in well-specified populations, of algorithms 
for the systematic assessment of patients with inconti- 
nence and of specific behavioral, pharmacologic, and 
surgical treatment, either alone or in combination. 

• Development of new therapies, including pharmaco- 
logic agents with greater specificity for the urinary 
tract and new behavioral and surgical strategies and 
other innovative techniques, including electrical 


• Urinary incontinence is very common among older 
Americans and is epidemic in nursing homes. 

• Urinary incontinence costs Americans more than $10 
billion each year. 

• Urinary incontinence is not part of normal aging, but 
age-related changes predispose to its occurrence. 

• Urinary incontinence leads to stigmatization and social 

• Of the 10 million Americans with urinary inconti- 
nence, more than half have had no evaluation or 

• Contrary to public opinion, most cases of urinary 
incontinence can be cured or improved. 

• Every person with urinary incontinence is entitled to 
evaluation and consideration for treatment. 

• Most health care professionals ignore urinary inconti- 
nence and do not provide adequate diagnosis and 

• Inadequate nursing home staffing prohibits proper 
treatment and contributes to the neglect of nursing 
home residents. 

• Medical and nursing education neglect urinary incon- 
tinence. Curriculum development is urgent. 

• A major research initiative is required to improve 
assessment and treatment for Americans with urinary 

Members of the Consensus Development Panel were: John W. Rowe, 

M. D., Conference and Panel Chairperson, President, The Mount 
Sinai School of Medicine and the Mount Sinai Hospital, New York, 

N. Y.; Richard W. Besdine, M.D., Conference and Panel Co-chair- 
person, Director, Travelers Center on Aging, Travelers Professor of 
Geriatrics and Gerontology, University of Connecticut Health Center, 
Farmington, CT; Amasa B. Ford, M.D., Professor of Epidemiology 
and Biostatistics, Associate Dean for Geriatric Medicine, Department 
of Epidemiology and Biostatistics, Case Western Reserve University 
School of Medicine, Cleveland, Ohio; Cheryle B. Gartley, President 
and Founder, The Simon Foundation for Continence, Director, Con- 
tinence Awareness, Research, and Education Center, Wilmette, 111; 
Donald M. Gleason, M.D., Director, Urodynamics Laboratory, Tuc- 
son Medical Center, Clinical Professor, Department of Surgery (Urol- 
ogy), University of Arizona, Tucson, Ariz.; Frank C. Greiss, Jr., M.D., 
Frank R. Lock Professor and Chairman, Bowman Gray School of 
Medicine, of Wake Forest University, Winston-Salem, NC; William C. 
de Groat, Ph.D., Professor of Pharmacology, Departments of Phar- 
macology and Behavioral Neuroscience, University of Pittsburgh Med- 
ical School, Pittsburgh, Pa; Argye Hillis, Ph.D., Associate Professor, 
Texas A & M College of Medicine, Director, Section of Biostatistics, 
Scott and White Hospital, Temple, Tex; Jeanie Kayser-Jones, R.N., 
Ph.D., F.A.A.N., Professor, Department of Physiological Nursing and 
Medical Anthropology Program, University of California, San Fran- 
cisco, San Francisco, Calif; George A. Kaplan, Ph.D., Chief, Human 
Population Laboratory, California Department of Health Services, 
Berkeley, Calif; A. Richard Kendall, M.D., Professor and Chairman, 
Department of Urology, Temple University School of Medicine, Phi- 
ladelphia, Pa; Neal E. Miller, Ph.D., D.Sc., Professor Emeritus, Rock- 
efeller University, Research Affiliate, Department of Psychology, Yale 
University, New Haven, CT; James R. Scott, M.D., Professor and 
Chairman, Department of Obstetrics and Gynecology, University of 
Utah School of Medicine, Salt Lake City, Utah; Joanne Sabol Steven- 
son, Ph.D., R.N., Professor, Department of Life Span Process, Ohio 
State University College of Nursing, Columbus, Ohio; Robert B. 
Wallace, M.D., M.Sc., Professor and Head Department of Preventive 
Medicine and Environmental Health, University of Iowa, Iowa City, 

Members of the Planning Committee were: Evan Hadley, M.D., 
Chief, Geriatric Branch, National Institute on Aging, National Insti- 
tutes of Health, Bethesda, MD; Joseph E. Binard, M.D., F.R.C.S.(c), 
Director, Spinal Cord Injury Service, Veterans Administration Central 

Office, Washington, D.C.; Carol A. Brink, M.P.H., R.N., Senior 
Research Associate/ Lecturer, University of Rochester School of Nurs- 
ing, Rochester, N.Y.; Ananias C. Diokno, M.D., Clinical Professor, 
Surgery-Urology, University of Michigan, Chief of Urology, Depart- 
ment of Urology, William Beaumont Hospital, Royal Oak, Mich.; 
Jerry M. Elliott, Program Analyst, Office of Medical Applications of 
Research, National Institutes of Health, Bethesda, MD; J. Andrew 
Fantl, M.D., Associate Professor, Department of Obstetrics and 
Gynecology, Medical College of Virginia, Virginia Commonwealth 
University, Richmond, Va.; Herbert C. Lansdell, Ph.D., Health Scien- 
tist Administrator, Division of Fundamental Neurosciences, National 
Institute of Neurological and Communicative Disorders and Stroke, 
National Institutes of Health, Bethesda, Md.; Barbara McChesney, 
Conference Coordinator, Prospect Associates, Rockville, Md.; E. 
Patricia McCormick, Ph.D., R.N., Chief, Acute and Chronic Illness 
Branch, Extramural Programs, National Center for Nursing Research, 
National Institutes of Health, Bethesda, Md.; Marcia G. Ory, Ph.D., 
M.P.H., Chief, Social Science Research on Aging, Behavioral and 
Social Research Program, National Institute on Aging, National Insti- 
tutes of Health Bethesda, Md; Charles H. Rodgers, Ph.D., Director, 
Manpower Program, Division of Kidney, Urologic, and Hematologic 
Diseases, National Institute of Diabetes and Digestive and Kidney 
Diseases, National Institutes of Health, Bethesda, Md; John W. Rowe, 

M. D., Panel and Conference Chairperson, President, The Mount 
Sinai School of Medicine and the Mount Sinai Hospital, New York, 

N. Y.; Belinda Traughber, Ph.D., Associate Professor of Psychology, 
Department of Psychology, Middle Tennessee State University, Mur- 
freesboro, Tenn; Michael J. Bernstein, Director of Communications, 
Office of Medical Applications of Research, National Institutes of 
Health, Bethesda, Md; Karen Pocinki, Writer and Editor, National 
Institute on Aging, National Institutes of Health, Bethesda, Md. 

The Conference was Sponsored by: National Institute on Aging, T. 
Franklin Williams, M.D., Director; Office of Medical Applications of 
Research, John H. Ferguson, M.D., Director; National Center for 
Nursing Research, Ada Sue Hinshaw, Ph.D., R.N., Director; National 
Institute of Diabetes and Digestive and Kidney Diseases, Phillip 
Gorden, M.D., Director; National Institute of Neurological and 
Communicative Disorders and Stroke, Murray Goldstein, D.O., 
M.P.H., Director; Veterans Administration, Thomas K. Tumage, 
Administrator of Veterans Affairs. 

VOLUME 53, NO. 1 


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Relationship of Syphilis to Drug Use and Prostitution: 
Connecticut and Philadelphia, Pennsylvania 


S INCE 1984, in many areas of the United States, 
reported rates of syphilis have greatly increased. 1 
Between 1984 and 1987, annual rates of syphilis (primary 
and secondary) increased 70% in the state of Connecticut 
and 74% in the city of Philadelphia (Figure 1). These 


60 -j 

. Philadelphia 





1984 1985 1986 1987 1988 

Figure 1 

Cases of primary and secondary syphilis, by quarter — Connecticut and 
Philadelphia, 1984-88. 

trends have continued in 1988; in the first quarter of this 
year, annualized rates increased by 70% in Connecticut 
and by 25% in Philadelphia compared with 1987 annual 
rates. Investigations were conducted at these two sites to 
identify factors associated with this increase. 

In Philadelphia and Connecticut, over 80% of all 
newly diagnosed patients with early syphilis are inter- 
viewed and counseled. Cases are detected through re- 
porting by public clinics and private health-care provid- 
ers and through laboratory screening. During the inter- 
views, information is collected about patients’ life-styles 
to help locate sexual contacts. In Philadelphia and Con- 
necticut, records from these interviews were abstracted 
and analyzed for the years 1985-87. In Connecticut, all 
interviews of persons with primary and secondary syphi- 

*Abstracted interviews consisted of all those conducted in the first 
three months of 1985 and 1986 and a systematically selected sample of 
two-thirds of interviews conducted in the first three months of 1987. 

Morbidity and Mortality Weekly Reports, Vol. 37, Nos. 46, 49 and 
50, 1988. 

lis were abstracted: in Philadelphia, a sample of inter- 
views* was chosen that involved persons with primary, 
secondary, and latent syphilis present less than one year. 

At both sites during the three-year period, the propor- 
tion of men with syphilis who reported sexual contact 
with men decreased substantially. In Connecticut, the 
proportion of men with syphilis who reported being 
homosexual or bisexual decreased from 38% (48/ 126) in 
1985 to 11% (21/ 197) in 1987; in Philadelphia, the per- 
centage declined from 53% (49/93) to 18% (25/137) 
during this three-year period. 

In contrast, recorded use of illicit drugs and reported 
prostitution or contact with a prostitute among hetero- 
sexual syphilis patients increased greatly during this 
period. Among females at both study sites, the propor- 
tion reporting to be prostitutes increased more than 
threefold and the proportion reporting use of drugs 
increased more than sixfold (Figure 2). Heterosexual 

Heterosexual Males. Connecticut 

Prostitute Contact 

0 5 10 15 20 25 



Heterosexual Males, Philadelphia 

— 1985 
i= 1986 
“ 1987 

0 5 10 15 20 




Figure 2 

Reported illicit drug use and prostitution among syphilis patients, by 
category and year — Connecticut and Philadelphia, 1985-87. 

male syphilis patients showed similar but smaller in- 
creases in recorded drug use. Prostitute contact by this 
group occurred more frequently in Connecticut than in 
Philadelphia but increased at both sites. 

Reported by: G Joachim, JL Hadler, MD, State Epidemiologist, 

VOLUME 53, NO. 1 


Connecticut Department of Health Services. M Goldberg, RG Shar- 
rar, MD, Philadelphia Department of Public Health; R David, MD, 
State Epidemiologist, Pennsylvania State Department of Health. Div- 
ision of Sexually Transmitted Diseases, Center for Prevention Servi- 
ces; Division of Field Services, Epidemiology Program Office, CDC. 

Editorial Note: Although prostitution has long been 
associated with syphilis (and other sexually transmitted 
diseases), 2 it appears to have been relatively unimportant 
in the overall epidemiology of syphilis in the United 
States during the last two decades. V Drug use has only 
recently been associated with the spread of syphilis. 1 
Since drug use and prostitute contact were not recorded 
systematically on case interview forms, the true frequency 
of these behaviors among syphilis patients is probably 
underestimated. This underreporting of these behaviors, 
if combined with changing interviewers’ perceptions, 
could bias the findings in Connecticut and Philadelphia. 
However, the consistency between the two sites and the 
magnitude of the increase in reporting of prostitution 
and drug use suggest that the trends observed in Connec- 
ticut and Philadelphia reflect real changes in the epide- 
miology of syphilis. 

The decrease in the proportion of male syphilis patients 
who are homosexual /bisexual has been noted in Cali- 
fornia and New York City, 5 in outbreaks in Manitoba 6 
and Florida, 7 and in a sample of states with recent 
increases in syphilis. 8 In the Florida outbreak, prostitutes 
were also found to be an important risk group. The 
results of the studies in Connecticut and Philadelphia 
support these other findings and suggest that the emer- 
gence of syphilis among prostitutes, drug users, and their 
sexual contacts may be a widespread national pheno- 

The possibility of an increase in syphilis among per- 
sons in these risk groups has important implications for 
the control of syphilis and other sexually transmitted 
diseases, including human immunodeficiency virus (HIV) 
infections. Prostitutes tend to have large numbers of 
anonymous sexual partners who are difficult to locate by 
traditional methods of partner notification. Prostitutes 
who also frequently use intravenous (IV) drugs and, in 

some parts of the country, those with a history of IV- 
drug use have high rates of infection with HIV. 9 Recent 
studies have suggested that sexually transmitted diseases 
that cause genital ulcers, such as syphilis, greatly increase 
the likelihood that HIV infection, when present, will be 
transmitted. 10-12 To limit the spread of syphilis, which 
may also help limit the spread of HIV, public health 
officials may need to modify current control methods to 
better identify and treat syphilis-infected prostitutes, 
drug users, and their sexual contacts. 1 


1. CDC: Syphilis and congenital syphilis — United States, 1985-88. 
MMWR 1988;37:486-9. 

2. Brandt AM: The syphilis epidemic and its relation to AIDS. 
Science 1988;239:375-80. 

3. Willcox RR: Prostitution and venereal disease. Br J Vener Dis 

4. Perine PL, Handsfield HH, Holmes KK, Blount JH: Epidemiol- 
ogy of the sexually transmitted diseases. Ann Rev Public Health 

5. CDC: Increases in primary and secondary syphilis — United States. 
MMWR 1987;36:393-7. 

6. Lee CB, Brunham RC, Sherman E, Harding GKM: Epidemiology 
of an outbreak of infectious syphilis in Manitoba. Am J Epidemiol 

7. CDC: Early syphilis — Broward County, Florida. MMWR 1987; 

8. CDC: Continuing increase in infectious syphilis — United States. 
MMWR 1988;37:35-8. 

9. CDC: Human immunodeficiency virus infection in the United 
States: a review of current knowledge. MMWR 1987;36(suppl 

10. Cameron DW, D’Costa LJ, Ndinya-Achola JO, Piot P, Plummer 
FA: Incidence and risk factors for female to male transmission of 
HIV [Abstract], IV International Conference on AIDS. Book 1. 
Stockholm, June 12-16, 1988:275. 

11. Simonsen JN, Cameron DW, Gakinya MN, et al: Human immu- 
nodeficiency virus infection among men with sexually transmitted 
diseases: experience from a center in Africa. N Engl J Med 

12. Holmberg SD, Stewart JA, Gerber AR, et al: Prior herpes simplex 
virus type 2 infection as a risk factor for HIV infection. JAMA 

State and Local Influenza Immunization Program Activities 

I NFLUENZA prevention and control efforts in the 
United States have relied on cooperation between 
federal, state, and local public health agencies and pri- 
vate sector providers. Since the 1979-80 influenza sea- 
son, public sector resources for influenza control have 
been provided primarily by state and local health 

Between the 1985-86 and 1986-87 influenza seasons, 
the number of state and local projects offering influenza 
vaccine increased markedly. During the 1985-86 influ- 

enza season, 20 of 63 federal immunization grant-sup- 
ported localities reported purchasing approximately 
1,710,024 doses of influenza vaccine for use in public 
clinics. During the 1986-87 influenza season, 36 localities 
reported purchasing 2,179,485 doses of influenza vac- 
cine. Compared with the previous year, the activities in 
1986-87 represented increases of 80% in project partici- 
pation and 27% in the number of doses purchased. 

Programs in Allegheny County, Pennsylvania, and in 
California and Vermont illustrate state and local efforts 



to improve influenza vaccine coverage. 

Allegheny County, Pennsylvania. During the 1986-87 
influenza season, the Allegheny County Health Depart- 
ment conducted expanded outreach clinics to immunize 
high-risk persons against influenza. Of the 10,200 per- 
sons residing in nursing home facilities, 8529 (84%) 
received vaccine provided by the health department. 
Previous immunization coverage levels in Allegheny 
County nursing homes ranged from a low of 36% in the 
1979-80 influenza season to a high of 71% during the 
1985-86 season. An additional 43,926 doses were admin- 
istered in health department clinics, hospital outpatient 
departments, community clinics, and senior citizen facili- 
ties. An estimated 2 1 % of the 2 1 0,000 persons >65 years 
of age who were not in long-term-care facilities received 
publicly purchased vaccine. Allegheny County coordi- 
nated the development of a coalition involving the Amer- 
ican Lung Association (ALA) of Western Pennsylvania 
and other health-care organizations that conducted sur- 
veys to measure the impact of and coverage levels for 
their programs. A telephone survey conducted by the 
ALA at the conclusion of the 1986-87 influenza season 
showed overall influenza vaccination rates of 32% in 
noninstitutionalized persons aged >65 years in the 
general population. The ALA publicized the recom- 
mendations and distributed educational material to high- 
risk groups. 1 

California. The State of California, through the Cali- 
fornia Department of Health Services (CDHS), distrib- 
uted over 481,000 doses of influenza vaccine, of which 
over 350,000 doses were administered to approximately 
12% of California residents >65 years of age. This pro- 
gram, in operation since 1974, is funded entirely through 
state general revenue funds. The CDHS distributes vac- 
cine to 59 county and municipal health departments. 
Fees up to $2.00 may be charged by local units to defray 
administrative costs. Vaccine is offered at clinics to all 
persons >55 years of age and to persons of any age with 
certain chronic illnesses. Staff for outreach clinics and 
nursing home programs is provided jointly by California 
chapters of the American Red Cross and state and local 
health departments. 

Vermont. The Vermont Department of Health receives 
a yearly grant from Blue Cross/ Blue Shield of Vermont 
to support the purchase of influenza vaccine for an 
immunization program for persons >60 years of age and 
persons of all ages with high-risk conditions. Vaccine is 
distributed to home health agencies and visiting nurse 
associations that provide staffing and clinic coordina- 
tion. Area Offices on Aging provide additional coordina- 
tion and publicity through a newsletter distributed to 
senior citizens of Vermont. During the 1987-88 influenza 
season, approximately 1 1,000 persons received influenza 
vaccine through this program. 

Reported by: Allegheny County Health Department, Pittsburgh; R 
David, MD, Acting State Epidemiologist, Pennsylvania Department 
of Health. DO Lyman, MD, State Epidemiologist, California Depart- 

ment of Health Services. RL Vogt, MD, State Epidemiologist, Ver- 
mont Department of Health. Division of Immunization, Center for 
Prevention Services, CDC. 

Editorial Note: Older persons and those with certain 
chronic health problems are at increased risk for compli- 
cations of influenza infection. Target groups for influenza 
immunization include children and adults with cardio- 
pulmonary or renal disease, metabolic diseases (includ- 
ing diabetes mellitus), severe anemia, or compromised 
immune function; residents of chronic-care facilities; 
health-care professionals caring for high-risk patients; 
and household contacts of high-risk persons. 2 

As many as 50,000 excess deaths are caused by in- 
fluenza in the United States during epidemic years. 
Although influenza vaccine can substantially reduce 
influenza-associated morbidity and mortality, only about 
20% of high-risk persons are immunized annually. To 
increase coverage, many state and local health depart- 
ments have collaborated with private sector groups to 
develop special influenza vaccination programs such as 
those reported above. In addition, in October 1988, 
CDC, in collaboration with the Health Care Financing 
Administration, awarded demonstration grant funds to 
nine programs to assess the cost effectiveness of furnish- 
ing influenza vaccine to Medicare part B beneficiaries. 

In the hospital setting, influenza vaccine should be 
offered to high-risk persons between September and 
February. 2 Although other organized vaccination cam- 
paigns for high-risk persons are optimally undertaken in 
November, health-care providers should make every 
effort to ensure that high-risk persons are immunized 
during routine health-care contacts during the fall and 
early winter. Studies suggest that at least 40%-55% of 
persons who are at high risk or who died of influenza and 
pneumonia may have received care in a health-care insti- 
tution during the previous year; at least 75% of these 
persons have attended outpatient clinics but failed to 
receive influenza vaccine when vaccines should have 
been routinely available. 2-4 Recognizing these missed 
opportunities is important in improving coverage levels 
in high-risk groups. 

Because of its substantial health impact, influenza is 
one of the most important vaccine-preventable diseases 
of adults. All providers of health care to adults should 
take every opportunity to review the immunization sta- 
tus of patients and, when indicated, offer their patients 
influenza vaccine and other vaccines (pneumococcal, 
tetanus/ diphtheria toxoids, measles-mumps-rubella, and 
hepatitis B) appropriate for adults. 


1 . CDC: Allegheny County 1 986-87 influenza vaccination program — 
Pittsburgh, Pennsylvania. MMWR 1987;36:617-9. 

2. ACIP: Prevention and control of influenza. MMWR 1988; 

3. Barker WH, Mullooly JP: Pneumonia and influenza deaths dur- 
ing epidemics: implications for prevention. Arch Intern Med 1982: 

4. Williams WW, Hickson MA, Kane MA, et al: Immunization 
policies and vaccine coverage among adults: the risk of missed 
opportunities. Ann Intern Med 1988;108:616-25. 

VOLUME 53, NO. 1 


Hypothermia Prevention 

F ROM 1 976 through 1985, 7,450 deaths were caused 
by exposure to cold* in the United States (Figure 1). 
Of health effects associated with cold exposure, hypo- 
thermia — defined as a core body temperature of <35C 
(<95F) — is the most commonly fatal syndrome. Per- 
sons >60 years of age are particularly susceptible to 
hypothermia and account for more than half of all 
deaths. 1 Younger persons subjected to overwhelming 
cold stress are also vulnerable. 2 Although deaths attribut- 
able to hypothermia occur infrequently in children, in- 
fants less than one year of age are at relatively high risk. 
Rates of death from hypothermia are generally higher in 
males than in females, but these differences are less 
substantial in children and the elderly. 3 


Figure 1 

Deaths attributable to excessive cold exposure — United States, 

Persons with hypothyroidism are at increased risk for 
hypothermia. 4 In addition, a variety of drugs, principally 
sedative-hypnotics, may predispose users to hypother- 
mia; ethanol and neuroleptic medications particularly 
increase susceptibility to cold. 2 

As the body temperature of a cold-exposed person 
decreases, impaired consciousness, confusion, or disor- 
ientation may occur. Because mental status is altered, a 
mildly hypothermic persons may fail to take appropriate 
corrective measures to lessen exposure. In response to 

* Deaths attributed to excessive cold (ICD code E901) were analyzed 
using mortality data tapes for 1976-85 from the National Center for 
Health Statistics. 

the decline in core temperature, vasoconstriction (caus- 
ing pallor) and shivering occur. However, shivering 
decreases markedly in severe hypothermia because ther- 
moregulation becomes impaired. Severely hypothermic 
persons lose consciousness and develop shallow respira- 
tions. Ventricular fibrillation and death may follow. 2 

Reported by: Health Studies Br, Division of Environmental Hazards 
and Health Effects, Center for Environmental Health and Injury Con- 
trol, CDC. 

Editorial Note: This preliminary study of mortality sug- 
gests a trend toward increased incidence of hypothermia. 
Although age-adjusted rates are required to properly 
evaluate the hypothesis that mortality due to effects of 
cold is increasing, the crude numbers of deaths (Figure 1) 
strongly suggest such a trend. 

Hypothermia prevention programs should focus on 
persons particularly susceptible to hypothermia and those 
likely to be subjected to unusual cold stress. Persons 
caring for the elderly should be alerted to hypothermia’s 
symptoms and signs, and elderly persons living alone 
should be visited frequently. Since adequate caloric 
intake is important in preventing hypothermia, programs 
designed to improve nutrition in the elderly may also be 
helpful. Programs that ensure home heating for the 
elderly may also help prevent hypothermia. 

Younger persons likely to be subjected to cold stress 
(eg, skiers and hikers) should be educated concerning the 
need for adequate clothing and the importance of ab- 
staining from alcohol use during prolonged cold expo- 
sure. Shelter should be offered to homeless persons who 
would otherwise sleep outdoors on cold winter nights. 

Persons using medications (particularly neuroleptic 
medications) that are likely to increase susceptibility to 
the cold should be advised by their physicians regarding 
their increased vulnerability to cold stress. 


1. Kilbourne EM: Illness due to thermal extremes. In: Last JM, ed. 
Maxcy-Rosenau public health and preventive medicine. 12th ed. Nor- 
walk, Connecticut: Appleton-Century-Crofts, 1986:711-4. 

2. Collins KJ: Hypothermia: the facts. New York: Oxford University 
Press, 1983. 

3. CDC: Hypothermia-associated deaths — United States, 1968-80. 
MMWR 1985;34:753-4. 

4. Forester CF: Coma in myxedema; report of a case and review of 
the world literature. Arch Intern Med 1963;! 1 1:734-43. 



State-Specific Estimates of Smoking- Attributable Mortality 
and Years of Potential Life Lost— United States, 1985 

C IGARETTE smoking is the chief avoidable cause 
of death in the United States. 1 Although annual 
estimates of smoking-attributable mortality in the Unit- 
ed States vary by method and data source, the estimates 
are uniformly large and range from a low of 270, 000 2 to a 
high of 485, 000. 3 An estimated 320,515 deaths were 
attributable to smoking in 1984, 4 representing approxi- 
amately 16% of the total deaths in the United States for 
that year. Years of potential life lost (YPLL) have also 
been used to measure the impact of smoking-attributable 
disease. 4 ’ 5 

In 1987, a computer software program (Smoking- 
Attributable Mortality, Morbidity, and Economic Cost 
(SAMMEC) developed by the Center for Nonsmoking 
and Health, Minnesota Department of Health was dis- 
tributed by CDC to other states. 6 This software 
facilitates calculations of smoking-attributable mortal- 
ity, YPLL, and economic costs. Using the software, all 
50 states and the District of Columbia completed these 
calculations for 1985. 

For smoking-attributable deaths and YPLL, the smok- 
ing -attributable fractions (SAFs) for 21 smoking-related 
diseases among adults were calculated using weighted 

relative risks estimated from four prospective studies on 
the health effects of smoking. 2 ’ 4 In addition, risks for 
four pediatric diseases related to maternal smoking were 
included in the SAMMEC calculations. 7 Age- and sex- 
specific mortality data for 1985 were obtained from each 
state’s vital records system. Age- and sex- specific weight- 
ed smoking prevalence rates (CDC, unpublished data) 
were obtained from the 1985 Current Population Survey 
(supplement) of the U.S. Bureau of the Census. The 
smoking-attributable YPLL were calculated by two meth- 
ods: 1) to age 65 years and 2) to average life expectancy. 5 
State-specific rates per 100,000 persons for smoking- 
attributable mortality and YPLL were calculated using 
state-specific population data provided by the U.S. Bu- 
reau of the Census for 1985 (U.S. Bureau of the Census, 
unpublished data). These rates were not age-adjusted 
because insufficient age-specific population data were 
available to permit it for all states. 

According to state-specific estimates, more than 
314,000 U.S. deaths were caused by smoking in 1985. 
The average number of smoking-attributable deaths per 
state was 6168 (ranging from 271 in Alaska to 28,533 in 
California). Of all smoking-attributable deaths in the 

Table 1 






YPLL before 
age 65 

YPLL before 
life expectancy 





YPLL before 
age 6 5 

YPLL before 
life expectancy 





















New Hampshire 








New Jersey 








New Mexico 








New York 








North Carolina 








North Dakota 




District of Columbia 




























2 252 

10 527 









Rhode Island 








South Carolina 








South Dakota 
























































West Virginia 




































VOLUME 53, NO. 1 


United States, 67% were among men, 32% among wo- 
men, and less than 1% among children less than 5 years 
of age. These deaths in young children resulted from low 
birthweight/ short gestation, respiratory distress syn- 
drome, other respiratory diseases of the newborn, and 
other diseases of children associated with maternal smok- 
ing. 4 Smoking-attributable deaths accounted for approx- 
imately 936,000 YPLL before age 65 years in 1985. When 
average life expectancy was used as a cut-off point, 
approximately 3.6 million YPLL resulted from the smok- 
ing-attributable deaths. 

The average state smoking-attributable mortality rate 
was 130.0 per 100,000 persons (ranging from 45.3 in 
Utah to 175.9 in Kentucky). The average rate of smok- 
ing-attributable YPLL before age 65 years was 447.8 per 
100,000 persons less than 65 years of age (ranging from 
223.5 in Utah to 773.6 in the District of Columbia). The 
average rate of smoking-attributable YPLL before actual 
life expectancy was 1503.8 per 100,000 persons (ranging 
from 643.2 in North Dakota to 2167.3 in Kentucky). 

Reported by: CH Woernle, MD, State Epidemiologist, Alabama Dept 
of Public Health. J Wohlleb, MS, Div of Health Statistics, Arkansas 
Dept of Health. L Parker, PhD, Chronic Disease Br, California Dept 
of Health Svcs. W Todd, MS, Div of Prevention Programs, Colorado 
Dept of Health. M Adams, MPH, Office of Health Education, Con- 
necticut State Dept of Health Svcs. F Breukelman, Div of Public 
Health Education, Delaware Dept of Health and Social Svcs. V Kofie, 
PhD, Bur of Cancer Control, District of Columbia Dept of Health and 
Human Svcs. K Rigney, MD, Clth Promotion and Disease Prevention 
Section, Idaho Dept of Health and Welfare. L Hathcock, PhD, Public 
Health Statistics Div, Indiana Board of Health. M Eischen, Health 

Education and Risk Reduction Br, Iowa Dept of Public Health. R 
Schwartz, MSPH, Div of Health Promotion and Education, Maine 
Bureau of Health. N Fox, PhD, Chronic Disease Prevention Svcs, 
Maryland Dept of Health and Mental Hygiene. G Connolly, DDS, 
Office for Nonsmoking and Health, Massachusetts Dept of Public 
Health. C Daly, MPH, Center for Nonsmoking and Health, Minne- 
sota Dept of Health. N Gunther, MS, Public Health Statistics Br, 
Mississippi State Dept of Health. N Miller, MS, Office of Health 
Promotion, Missouri Dept of Health. R Moon, MPH, Health Svcs 
Div, Montana Dept of Health and Environmental Sciences. E Wieber, 
Health Promotion and Education Div, Nebraska Dept of Health. W 
Morell, Vital Statistics Bur, Nevada Dept of Human Resources. E 
Schwartz, PhD, Div of Public Health Svcs, New Hampshire Dept of 
Health and Human Svcs. B Lee, Div of Health Promotion and Educa- 
tion, North Dakota State Dept of Health and Consolidated Laborato- 
ries. J Cataldo, Office of Health Promotion, Rhode Island Dept of 
Health. P Lee, MPH, Dept of Health Education, South Carolina Dept 
of Health and Environmental Control. L Post, MPH, Center for 
Health Policy and Statistics, South Dakota Dept of Health. C Pear- 
son, MN, Div of Health Promotion, Tennessee Dept of Health and 
Environment. R Todd, MSEd, Office of Smoking and Health, Texas 
Dept of Health. C Chalkley, MHEd, Bur of Health Promotion and 
Risk Reduction, Utah Dept of Health. C Dickson, MS, Div of Health 
Promotion, West Virginia Dept of Health. M Futa, M A, Health Risk 
Reduction Program, Wyoming Dept of Health and Social Svcs. Div of 
Field Svcs, Epidemiology Program Office; Office on Smoking and 
Health, Center for Chronic Disease Prevention and Health Promo- 
tion, CDC. 

CDC Editorial Note: Smoking causes more premature 
deaths than all other health-risk behaviors in the United 
States. 8 The state-specific calculations of smoking-at- 
tributable mortality permit comparison of the impact of 
smoking with that of other health risks in states. Even as 

Table 2 




YPLL before 
age 65 

YPLL before 
life expectancy 

































District of Columbia 














































































YPLL before 
age 6 5 

YPLL before 
life expectancy 









New Hampshire 




New Jersey 




New Mexico 




New York 




North Carolina 




North Dakota 




















Rhode Island 




South Carolina 




South Dakota 




























West Virginia 






















smoking prevalence declines in this country, 9 smoking- 
attributable illness will continue to produce an enormous 
disease burden well into the 21st century. 10 Thus, efforts 
to reduce tobacco use in each state must continue to be a 
high public health priority. 

The national estimate for the total number of smok- 
ing-attributable deaths reported here is remarkably sim- 
ilar to the 1984 estimate (320,5 15), 4 despite the following 
differences in the methods used to calculate the two 
estimates: 1) the 1985 state-specific mortality data were 
used in these calculations rather than 1984 national mor- 
tality data; 2) different SAFs for lung cancer among 
women were used in the two calculations; and 3) deaths 
among nonsmokers caused by passive smoking (3825) 
and deaths from cigarette-caused fires (1570) were in- 
cluded in the previous estimate 4 but not in the state- 
specific estimates used here. 

The longitudinal studies used to derive relative risk 
estimates for the SAMMEC calculations involved per- 
sons who began smoking between 1900 and 1950. The 
pattern of smoking among U.S. men was well-established 
by the end of that period; however, women did not begin 
smoking in large numbers until the 1950s and 1960s. 11 
Therefore, the results produced by SAMMEC probably 
underestimate the actual disease impact of smoking 
among women in 1985. 

The smoking-attributable mortality and YPLL rates 
reported here were not age-adjusted, thus limiting com- 
parisons among states. Despite these limitations, 
SAMMEC is a useful epidemiologic tool that helps 
organize and translate surveillance data into an under- 
standable framework. Some states have already reported 
their use of the data produced by SAMMEC. 12 * 14 The 
SAMMEC software also demonstrates the effectiveness 
of public health surveillance data when linked by state 
epidemiologists, state-based health promotion profes- 
sionals, state vital records departments, federal public 

health agencies, and others in addressing smoking and 
other problems. 


1 . Office on Smoking and Health: The health consequences of smok- 
ing: cancer — a report of the Surgeon General. Rockville, Mary- 
land: US Department of Health and Human Services, Public 
Health Service, 1982:xi;DHHS publication no. (PHS)82-50179. 

2. Rice DP, Hodgson TA, Sinscheimer P, Browner W, Kopstein AN: 
The economic costs of the health effects of smoking, 1984. Mil- 
bank Mem Fund Q 1986;64:489-547. 

3. Ravenholt RT: Tobacco’s impact on twentieth-century U.S. mor- 
tality patterns. Am J Preventive Med 1985; 1(4):4-17. 

4. CDC: Smoking-attributable mortality and years of potential life 
lost— United States, 1984. MMWR 1987;36:693-7. 

5. CDC: Premature mortality in the United States: public health 
issues in the use of years of potential life lost. MMWR 1986: 
35(suppl 2S). 

6. Shultz JM. SAMMEC: smoking-attributable mortality, morbid- 
ity, and economic costs (computer software and documentation). 
Minneapolis: Minnesota Department of Health, Center for Non- 
smoking and Health, 1986. 

7. McIntosh ID: Smoking and pregnancy: attributable risks and 
public health implications. Can J Public Health 1984;75:141-8. 

8. Warner KE: Health and economic implications of a tobacco-free 
society. JA MA 1987;258:2080-6. 

9. CDC: Cigarette smoking in the United states, 1986. MMWR 

10. Brown CC, Kessler LG: Projections of lung cancer mortality in the 
United States: 1985-2025. J Natl Cancer Inst 1988;80:43-51. 

1 1. Warner KE, Murt HA: Impact of the anti-smoking campaign on 
smoking prevalence: a cohort analysis. J Public Health Policy 

12. Schultz JM, Moen ME, Pechacek TF, et al: The Minnesota Plan 
for Nonsmoking and Health: the legislative experience. J Public 
Health Policy 1986;7:300-13. 

13. Vermont Department of Health: The public health impact and 
economic costs of cigaratte smoking. Vermont, 1985. Dis Control 
Bull , May 1987. 

14. Woernle CH: The burden of cigarette smoking in Alabama, Ala- 
bama Department of Public Health Epidemiol Rep 1987; 1(5): 1-2. 

VOLUME 53, NO. 1 


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View from the Hill 


I T would be difficult to exaggerate the timeliness — or 
to challenge the basic rationale — of the resource- 
based relative-value scale (RBRVS) study released Sep- 
tember 29 by the study’s project director, William C. 
Hsiao, Ph.D., of the Harvard School of Public Health, 
Boston. A number of distinguished colleagues have 
served with Dr. Hsiao in this impressive, congressionally 
mandated effort to develop a new and more equitable 
formula for reimbursing physician services rendered to 
Medicare patients. 

With the assistance and encouragement of the Health 
Care Financing Administration, the Physician Review 
Commission, and many physicians and members of 
Congress, this report offers the prospect of bringing 
Medicare physician costs under a type of control totally 
different from, but equally effective as and (one must 
hope) eminently more acceptable to the profession than 
the DRG formula. The DRG device has been applied, 
with highly questionable satisfaction, to Medicare hospi- 
tal charges since 1983. It is admittedly inapplicable and 
unadaptable to the reimbursement of physicians’ services 
under Medicare. 

The current levels of compensation for physician ser- 
vices ride on a movable base of usual, customary and 
reasonable (UCR) charges, a sort of vague tautology that 
offers both a comforting ring of flexibility and a tone of 
homey warmth and rationality. Whatever else may be 
said for it, UCR lends itself to outlandish inflation of 
charges and notable distortion of reimbursements for 
procedural services relative to those for cognitive services. 

This report by Dr. Hsiao and his colleagues presents 
resource-based relative values (RBRVs) for selected pro- 
cedures of four major specialties — family practice, inter- 
nal medicine, general surgery, and thoracic and cardio- 
vascular surgery. The program, as outlined in the “Special 
Report” published in The New England Journal of Med- 
icine, September 29, compares fees and charges for typi- 
cal services in the illustrative specialties, as calculated (in 
relative value point terms) with 1986 mean Medicare 
submitted charges. In each case, the total RBRV is 
shown as the sum of factors for intra-service work, pre- 
and post-service work, the opportunity cost of specialty 

JAMES E. BRYAN, Washington Correspondent, American Fam- 
ily Physician. 

Reprinted from American Family Physician. Copyright 1988 by 
American Academy of Family Physicians. 

training, and the relative practice costs inherent to the 

The investigators suggest that RBRVs “might well be 
quite different from charge-based relative values, pro- 
ducing fees that would differ from current charges and 
altering physicians’ economic incentives.” They note 
that, in consequence, “such a change in incentives might 
influence physicians’ practice patterns, although how 
strong an influence it would exert is still unresolved and 
vigorously debated.” The investigators suggest that “at 
least theoretically, total health care costs could be reduced 
by an alteration of physicians’ practice patterns.” 

Predictably, applying the RBRVS fee schedule (de- 
nominated in nonmonetary units) to conversion factors 
(so many dollars per unit) — as would presumably be 
done eventually, using conversion factors to reach nego- 
tiated fee schedules in various areas — would result in 
quite different levels of remuneration for various special- 
ists than obtained today among these groups. Speaking 
to this point in an accompanying “Sounding Board” 
statement, William L. Roper, M.D., HCFA spokesman, 
associates himself as a pediatrician and the Secretary of 
Health and Human Services, Otis Bowen, M.D., as a 
family physician in sharing the concern with the problem 
of “perceived inequities in [Medicare] payment across 
different specialties and services.” He observes, “Many 
have suggested that surgical and diagnostic services have 
been relatively overpaid, and that cognitive or primary 
care services have been relatively underpaid.” Dr. Roper 
warns against accepting the RBRVS as a “magic bullet,” 
noting that “the critical problems of increasing volume 
and intensity would remain, as they would under any 
fee-for-service system.” 

Generally speaking, the committee’s account of the 
manner in which it approached its charge, the imagina- 
tion, care and industry it brought to an unprecedented 
pioneering enterprise is difficult to fault. The committee 
augmented its technical work with many formal consul- 
tations with physicians, third-party payers, consumers 
and health service researchers. A prestigious and broadly 
representative advisory committee was designated and, 
under its subcontract calling for support and assistance 
from the American Medical Association, consultation 
was extended among many physicians. More than 30 
specialty societies each nominated three representatives, 
assuring adequate representation geographically as well 

VOLUME 53, NO. 1 


as between academic and clinical practices. RBRVs were 
developed for approximately 2,000 services, accounting 
for about 80 percent of Medicare payments to physicians 
in 14 specialties. 

Under an RBRVS fee schedule, the most sharply 
affected specialties would be family practice, internal 
medicine, allergy, ophthalmology and thoracic surgery. 
“An average family physician could receive 60 to 70 
percent more in revenues from the Medicare program. 
By contrast, the average ophthalmologist and thoracic 
and cardiovascular surgeon could receive 40 to 50 per- 
cent less,” according to the committee. Such a schedule is 
projected to have “very little effect” on the revenues of 
physicians specializing in obstetrics and gynecology, 
orthopedics, otolaryngology, psychiatry or urology. 

Finding no “gold standard” by which its work might 
be measured, the committee turned to a roughly com- 
parable experience in Ontario. Since the early 1970s, 
Ontario’s provincial fee schedules have been established 
through negotiation between the provincial government 
and the provincial medical society. After agreement is 
reached, the medical association brings together repre- 
sentatives of the various specialties to negotiate a uni- 
form and equitable schedule among themselves. 

The committee found, as a “general pattern,” that 
“most evaluation and management services have lower 
ratios than do services in the other categories. In other 
words, relative to resource cost, these services are com- 
pensated at a lower rate than invasive, imaging and 
laboratory services ... at less than half the rate of invasive 
services.” This applies whether the evaluation and man- 
agement services are performed by surgeons, internists 
or family physicians. The committee also found that 
such services tend to be more adequately compensated in 
hospitals than in office settings. 

The work of the Hsiao group responds to a public 
need to rationalize a substantial public beneficence. Just 
as water seeks its level, so public disbursements tend 
ultimately to relate themselves to the real costs of the 
private goods or services provided. The profession, I 
venture to suggest, would be well advised to accept with 
grace the growing public perception that “cognitive med- 
icine” responds most directly to humanity’s deeply felt 
needs. Hence, the long-standing imbalance between the 
profession’s evaluation of procedural medicine on the 
one hand and evaluative-management services on the 
other is not only inherently unrealistic but increasingly 
rejected by the public. Equally pertinent here is the 
impending political review of Medicare health costs, in 
which medical charges historically offer a favorite target 
for budget balancers. 

The stakes in the coming debate over the RBRVS are 
high: The issues involve the professional integrity and the 
public respect of American medicine. An early decision 
will be damanded both by political pressures and the 
public interest. 


HCMA Shelter Clinic 

While serving on the HCMA’s Community Health Com- 
mittee in 1985, James G. Patillo, III, M.D., learned that the 
medical needs of the area’s homeless were not being addressed 
in city shelters. Recognizing that this population was at high 
risk for medical problems, Dr. Patillo and other committee 
members cleared a storage room in the South Park Inn emer- 
gency shelter. There, they set up an infirmary stocked with 
donations from hospitals and medical suppliers. Referral net- 
works were coordinated with area hospital clinics and HCMA 
physicians volunteers. 

The South Park Inn Medical Clinic (SPIMC) currently 
serves Hartford’s homeless population under the advisement of 
the HCMA as a student-run program of the University of 
Connecticut School of Medicine. Approximately 70 medical 
students participate in the operation of the clinic, which is open 
every Tuesday evening. It is staffed by two fourth-year medical 
students functioning as primary care givers; two second-year 
students to take histories and assist in physical exams; and a 
first-year student, who performs clerical duties. 

The students are supervised by physician preceptors, streng- 
thening the quality of care and providing the doctor an oppor- 
tunity for involvement in medical education and community 
service. Physicians serve on an advisory board comprising 
University of Connecticut professors, hospital, and HCMA 

The clinic is seeking physicians to volunteer on Tuesday 
evenings from 6 to 8 p.m. on an alternating schedule, once 
every two to three months. According to Kathy Pae, second- 
year medical student and director of physician volunteers at the 
clinic, support from HCMA members may enable them to 
open an additional night each week. To volunteer at the South 
Park Inn Medical Clinic, call Ms. Pae at 724-0071. 

HCMA Foundation Fund Drive 

The Hartford County Medical Foundation’s current annual 
fund drive has a goal this year of $4,500. 

Last year, 120 members contributed nearly $3,600 for the 
Foundation’s support to Charter Oak Terrace-Rice Heights 
Health Center, Community Health Services, the Medical Stu- 
dents’ South Park Inn project, and the University of Connecti- 
cut dean’s discretionary fund. In addition, the Samuel H. 
Cohn, MD memorial scholarship fund awarded a $1,000 scho- 
larship to William Webb, a fourth-year medical student at the 
University of Connecticut. 

Construction Begins At Yale 
On Center For Molecular Medicine 

— Yale University and its School of Medicine have begun 
construction of the Center for Molecular Medicine (CCM), a 
$34.6 million facility for both basic and clinical research. The 
center, a collaborative project of the School of Medicine and 
the Howard Hughes Medical Institute in Bethesda, Maryland, 
is scheduled to be completed in the fall of 1990, and will take 
advantage of the scientific advancements of the past two 
decades, such as recombinant DNA technology, to accelerate 
the transfer of new discoveries from laboratories to patients. 
According to Dr. Leon E. Rosenberg, dean of the School of 
Medicine, “This project holds tremendous potential for medi- 
cal progress at Yale. The center is one of the university’s most 
significant investments in basic sciences research of this genera- 
tion, and it will help to sustain Yale’s reputation at the forefront 
of medical research.” 



Rules for Surviving a Chief Medical Residency 


A LTHOUGH unsought admonitions abound, the 
literature offers scant advice for the incoming chief 
medical resident (CMR), especially concerning the tough- 
est parts of the job: efficiency and retaining sanity. The 
13 maxims in this article attempt to fill this void. A few 
came from outgoing CMRs, some from other people, 
and some incorporate published insights on physicians’ 
mental health. 1-7 All sit best on a pattern of constantly 
displayed energy, intelligence, and interpersonal skills. 

• Work on your life outside the hospital every day; 
cultivate your loved ones and your interests. This requires 
topmost priority in order to command sufficient atten- 
tion. Human relationships do not tolerate being put on 
hold; they grow with sustained work or they wither. Do 
not become the greatest chief resident ever at the expense 
of your marriage. Remember that an “understanding” 
spouse is a liability and, perhaps, a time bomb, whereas a 
demanding one is an asset. Friends, family, and espe- 
cially your own children must have your attention, 
regardless of the pressures on you. 

To keep your perspective on the chief residency, seek 
other kinds of personal development, too, whether read- 
ing detective stories, playing the cello, or writing to 
Congress. Physical exercise promotes mental well-being 
and combats stagnation. Like many other nonmedical 
activities, it can be shared with friends or family. Chief 
residency requires “people” skills rather than medical 
brilliance, and humanization serves the job best. You 
were a person long before you were a doctor, and you 
will be one long after the transitory chief residency ends. 
You should not lose yourself. 

• Spend part of each day on your own education and 
pleasure in medicine. Being CMR does not serve every 
professional need. If you take no time for personal edu- 
cation, the realization that you labor for others’ growth 
while no one fosters yours may embitter you. Medical 
treats during my year-long chief residency included es- 
tablishing physical findings rounds with students, taking 
clinical photographs, and reviewing autopsy hearts for 
correlations. Possibilities are endless; most dovetail with 
teaching or administration, but that is not a criterion. 
Reserve one hour per working day for this, and not by 
prolonging the day. 

• Staying longer at the hospital means collecting more 
work to do; resist the urge. Since work expands to fill 
time, the habit of completing tasks by some reasonable 
hour, such as 5:00 p.m., trims waste. Do not try to prove 

HENRY SCHNEIDERMAN, M.D., Assistant Professor of Medi- 
cine and Pathology, University of Connecticut School of Medicine, 
Farmington, CT. 

Reprinted with permission from Resident & Staff Physician © June 
1986 by Romaine Pierson Publishers, Inc. 

your dedication by staying late, and stay away from the 
hospital on weekends, unless something specific demands 
your presence. Telephone calls at home should be limited 
to emergencies, because they let the hospital metastasize 
into the farthest recesses of your life. They destroy peace 
far beyond the actual time spent on the wire, since you 
struggle to resume whatever preceded the interruption. 
Appoint the seniormost in-house resident to handle such 
off-hours problems as transfers to the Intensive Care 
Unit or disputes between ward teams, with instructions 
to call you only for extraordinary situations. Unlimited 
availability and attendant weariness form the popular 
image of the “real doctor,” and often our implicit one as 
well; but it is false and harmful. Equanimity serves bet- 
ter; you are more likely to come out swinging the next 
morning if you have really recuperated the night before. 

• If you are unhappy, consider that more work will 
seldom correct problems or make you feel better. Rec- 
ognize overwork and do not try to solve it by doing still 
more. In Rhoads’ study of overwork, 2 the traditional 
physician response of “digging in” worsened the basic 
lesion, exhaustion, and thus lowered efficiency; one tries 
harder and harder and falls farther behind. Rest, diver- 
sion, departure, even (heaven forbid!) a mental health 
day are not signs of moral degeneracy, but rather rational 
responses. Not every low feeling in the chief residency 
represents overwork, but unrecognized overwork always 
should be considered. 

• What else helps to avoid overwork? Learning to say 
No more often. CMRs must combat their deficiency of 
leukocyte negativity synthetase. If a request is reasonable 
and comes from someone who has been supportive, and 
if the chore is vital, and if it really calls for you, consider 
saying Yes. Otherwise, say No. Refusals are easier when 
you offer an alternative: “Could Dr. Jones do this?” 
However, never make the alternative the basis for re- 
fusal, or you will be scooped: “I already asked her,” or 
worse, “I don’t like her.” Preface refusal with something 
you control, such as “I’m too swamped this month.” 
Even the old adage “My chairman said ...” may threaten 
an old bull’s sense of clout and catch you in the cross fire. 
Beware of seduction. “You’re the best bedside teacher” 
usually heralds an improper request. 

• In addition to limiting work intake, survival requires 
that you plan your time carefully. Chief residency is rife 
with interruptions, and if you let chaos rule, it will. 
Distinction between the most important tasks and the 
most pressing is not always clear; leading questions may 
assist, such as “Who suffers if this isn’t done?” or “Will 
this matter six months hence?” Do not disregard your 
schedule, because intrusions and crises are inevitable. If 
you make lists divided into columns labeled Now, Today, 

VOLUME 53, NO. 1 


and This week, do not overload the Now column with 
tasks that are not urgent. Assign time limits to open- 
ended activities, such as medical student teaching, and 
adhere to them rigidly, or days will be gobbled up. 
Increase use of support people. When materials or ar- 
rangements are needed on short notice, you frequently 
do them yourself by default, which wastes time and 

Establishing a list of priorities involves recognizing 
that there are always too many tasks. A CMR’s time and 
energy are not infinite, and some plans, needs, and even 
persons cannot be addressed. The hospital and the pro- 
gram will never be perfect. To attack every loose end is 
akin to a sprint in the middle of a marathon. Letting go 
of tasks selectively, not randomly via exhaustion, requires 
ridding yourself of a swollen self-image and guilt asso- 
ciated with not being all things to all people. 

• Another key to avoiding burnout is to delegate re- 
sponsibility; do not try to do it all yourself. Even if it 
takes longer to teach another than to do the task your- 
self, benefits include greater involvement of the resident, 
nurse, or secretary, a greater sense of shared goals, di- 
minished reliance of the system on yourself, and a repu- 
tation for not being the path of least resistance. Some- 
times the problem is not to complete the task, but to find 
a mechanism that avoids being a workhorse. You do not 
have to prove yourself by doing everything. Some general 
medicine c.onsultations can go to the ward resident with 
the smallest service; scheduling, to a secretary or, per- 
haps, a machine; and responsibility for remedies, to 
those who created the problem. 

• Know the difference between your problems and oth- 
ers’. If you solve someone else’s problem, you guarantee 
an endless succession of parallel cases. Your duty is to 
explicate the situation and then to advise steps. If an 
intern says, “I have to change January call,” one fit 
answer is, “Leslie, you do have a problem, and this is 
whatyow need to do to solve it.” Based on a background 
of credibility and support, this response communicates a 
positive message about competence, rather than a putoff. 
A colleague once said, “Your job is to give ulcers, not to 
get one”; this hyperbole underscores that you cannot 
afford to shield trainees from too much stress when it 
means taking extra stress upon yourself. The CMR job 
description is to be a leader, not a martyr. If a resident is 
inundated with admissions, the CMR should not start 
doing workups; he should telephone the backup resident 
or even a protesting off-service resident for assistance. 

• If house staff complain about such steps, you may 
have to remind them that chief residency is not a democ- 
racy, nor a popularity contest. You should not bargain 
for house staff approval. This looms largest when the 
CMR is a third-year resident and feels he must appease 
former peers who are now subordinates. You cannot 
please everybody and should not waste time trying. If 
you avoid caprice and autocracy, propriety and decency 
will speak for themselves. 

• Do not apologize. When there is a conflict, an apology 
is often a false solution that implies culpability and is 

suitable only after wrongdoing. Apology can become a 
habit, and a demeaning one. Admit errors readily; any- 
thing less undercuts you. 

Beware of toxic personalities who twist an apology 
into an excuse for their own passive-aggressive behavior. 
They have no right to do so, for we all serve patient care. 
Wealth, power, publications, and fame are incidentals, 
possible only because society charges our profession with 
care of the sick. 

• Loyalty to patients outweighs loyalty to house staff 
department, or institution. This does not excuse self- 
righteousness, the ugliest form of self-indulgence. Such 
priority deserves enunciation, both at house officer or- 
ientation and when a conflict of interests is identified. 
Loyalty to patients implies attending to the mental 
health of the house staff, and to their program, since 
happy, well-rested house officers provide optimal care. 

• However, speak up whenever standards are failed, 
despite the universal tendency to avoid unpleasantness. 
If patients have been mistreated or responsibilities ig- 
nored, the medical analogy is the sore that festers rather 
than heals. Verbal discussion of failings is vital. Confron- 
tation must proceed with tact, an open mind for both 
facts and interpretation, and an ability to emphasize the 
positive. A dispassionate style helps, as well as a state- 
ment that everybody errs, including you. When a trainee 
repeatedly strays, written notice provides necessary doc- 
umentation; a carbon copy to the program director is a 
more overt threat. If concern for the feelings of the 
violator silences you, you may find yourself telling the 
recalcitrant offender, “Martin, that’s the sixth time you’ve 
left the hospital without signing out,” to which Martin 
will reply, “I always signed out. And no one ever had a 
problem with me before.” Consistency, openness, and 
constructive criticism allay the policeman image. 

• In summary, do not burn yourself out. Impatience and 
enthusiasm contribute to a CMR’s effectiveness, but 
only if they do not run wild. Keep some reserve for the 
next drastic crisis. Acknowledge mistakes without feel- 
ing that they must all be undone immediately. Do not 
take work home, and stay home when you are sick. The 
program stumbled along without your guidance last 
year, and it will again. Be as lenient with yourself as you 
are with your house staff or, better yet, your patients. 


1. Walker JI: Coping with the stress of medical practice. Conn Med 
45:593-96, 1981. 

2. Rhoads JM: Overwork. JAMA 237:2615-18, 1977. 

3. Brent RL, Brent LH: Medicine: An excuse from living. Resident 
and Staff Physician 12:61-65, 1978. 

4. McCue JD: The effects of stress on physicians and their medical 
practice. N Eng J Med 306:458-63, 1982. 

5. Bittker TE: Alcohol, drugs, and depression — Road to physician 
suicide. Consultant 12:175-79, 1980. 

6. Anonymous: The goal. JAMA 250:407, 1983. 

7. Schiedermayer D: The heart man. JAMA 246:2852, 1981. 

The author would like to thank Ms. Rosemaria Memoli for her 
invaluable editorial advice. 

This article is based on a presentation at The First National Confer- 
ence for Chief Medical Residents in Ann Arbor, Michigan on 13 May 



Cost-Containment and Medical Malpractice 


WTT 7HILE we recognize, realistically, that cost-con- 
V V sciousness has become a permanent feature of 
the health care system, it is essential that cost limitation 
programs not be permitted to corrupt medical judge- 
ment.” So wrote Judge J. Rowen of the California Court 
of Appeals in deciding the nation’s first case to test the 
issue of liability for patient injury resulting from deci- 
sions by physicians and third-party payors to restrict 
clinical services. 1 

Much has been written about the effects of changes in 
the organization and reimbursement mechanisms for the 
delivery of health care services on the traditional 
physician-patient relationship. 2-4 The ethical and legal 
duties that derive from that relationship require that the 
physician utilize all available resources for the benefit of 
his patient. That duty conflicts with cost-containment 
strategies, especially prospective payment systems, that 
create incentives to curtail utilization. Nevertheless, the 
patient who is injured when care that should have been 
provided is not provided will probably recover damages 
from someone. Mrs. Lois Wickline was such a patient 
who brought suit against a third-party payor. In deciding 
that case, the California court began the process of defin- 
ing the respective legal positions of providers, patients, 
and payors in that increasingly complex enterprise we 
know as “providing patient care.” 

Facts of the Case 

Mrs. Lois Wickline was, in 1974, a 45-year-old former 
model and beautician, mother of four, and sole support- 
er of her family since her husband had been invalided by 
injury and cardiac problems. That year she began exper- 
iencing back pain and some pain in her legs on walking. 
Her general practitioner physician, in consultation with 
a surgeon, diagnosed peripheral vascular disease. When, 
after a period of conservative management, her symp- 
toms persisted, an operation was recommended. Preau- 
thorization for a ten-day hospital stay was requested and 
granted by MediCal. She was admitted to a community 
hospital where a peripheral vascular surgeon performed 

JULIUS LANDWIRTH, M.D., J.D., Director, Department of 
Pediatrics and Advisor for Medical-Legal Affairs, Hartford Hospital, 
Hartford, CT. 

a bilateral aortofemoral bypass graft. 

Within a few hours after surgery had been completed a 
clot developed in the right femoral artery requiring a 
thrombectomy. She subsequently continued to have 
intermittent vascular spasm and marginally acceptable 
peripheral circulation. As the end of her authorized 
length of stay approached, her physicians felt that an 
additional eight days of hospitalization was indicated. 
Following the prescribed procedure, an application for 
an extension of hospital stay was completed and submit- 
ted to MediCal. The MediCal procedure was for the 
application to be reviewed by a Health Care Service 
Nurse based at a regional office. The nurse was autho- 
rized to approve requests but not to deny or authorize a 
lesser number of days than requested without first con- 
tacting a MediCal physician consultant. 

Upon review of the application, the MediCal nurse 
questioned the necessity for additional stay based on the 
information provided in the form. She therefore con- 
tacted a MediCal physician who reviewed the informa- 
tion on the form and authorized an additional four days. 

At the end of that time, Mrs. Wickline was discharged 
from the hospital. During the subsequent ten days she 
experienced progressively increasing pain in her legs. 
When seen again by her surgeon she had obvious signs of 
progressive vascular insufficiency and infection at the 
surgical site. She was admitted on an emergency basis 
but her condition worsened and amputation of her right 
leg ultimately was required. 

The Court’s Decision 

She retained a local law firm and filed a claim against 
the State of California for careless and negligent aban- 
donment while she was in need of continuing hospital 
care. (Interestingly, she refused to sue her physicians with 
whom she had excellent rapport.) She contended that 
had she remained in the hospital her complications 
would have been detected earlier and the amputation 
avoided. She also claimed that the MediCal nurse and 
physician consultant were negligent in never having 
talked with her or her physician nor having reviewed her 
medical record. Both sides agreed that the attending 
physician is generally in the best position to know what 
the patient’s needs are. However, the attending surgeon, 

VOLUME 53, NO. 1 


who testified that her condition on discharge was stable, 
although worrisome, also stated that he did not persist 
with further appeal of the decision because he felt that 
MediCal had the power to tell him when to discharge a 
patient. In a magazine interview, one of the physicians 
was later quoted as saying “This wasn’t the first time that 
had happened. I’ve had patients who couldn’t walk, and 
the MediCal people have said ‘He’s got to get out.’ I’ve 
said, ‘Please, at least see him,’ but they wouldn’t even do 
that.” 5 

The State argued that the discharge order written by 
the physicians indicated that they saw no compelling 
reason to keep her in the hospital. 

In his instructions to the jury, the judge stressed that 
the MediCal consultant was required to review the medi- 
cal information and determine if an eight-day extension 
of stay was necessary according to the usual standard of 
medical practice in the community. After only four 
hours of deliberation the jury reached a decision in favor 
of Mrs. Wickline and awarded her $500,000. 

The case was appealed in 1986, the State claiming it 
was not negligent as a matter of law. The State argued 
that the physicians discharged the patient based upon the 
prevailing standard of care and that MediCal took no 
part in the decision. 

Furthermore, the State argued that the standard of 
due care to be followed by the MediCal physician Con- 
sultant is to make decisions based on the information 
provided on the official form and not to solicit further 
information from the medical record, the attending phy- 
sician, or the patient. The Appellate Court reversed the 
lower court’s finding in this case with the following 

“Third party payors of health care services can be held 
legally accountable when medically inappropriate deci- 
sions result from defects in the design or implementation 
of cost-containment mechanisms, as for example, when 
appeals made on a patient’s behalf for medical or hospi- 
tal care are arbitrarily ignored or unreasonably disre- 
garded or overridden. However, the physician who 
complied without protest to the limitations imposed by a 
third party payor when his medical judgement dictates 
otherwise cannot avoid his ultimate responsibility for his 
patient’s care. He cannot point to the health care payor 
as the liability scapegoat when the consequences of his 
own determinative medical decision go sour. There is 
little doubt that Dr. Polansky was intimidated by the 
MediCal program, but he was not paralyzed... nor ren- 
dered powerless to act appropriately if other action was 
required under the circumstances.... This court appre- 
ciates that what is at issue here is the effect of cost- 
containment programs upon the professional judgement 
of physicians to provide hospital treatment to patients 
requiring the same. While we recognize realistically that 
cost-consciousness has become a permanent feature of 
the health care system, it is essential that cost-limitation 

programs not be permitted to corrupt medical judge- 
ment. We have concluded from the facts an issue here 
that in this case it did not.” 


The California Court has set the stage for analysis of 
future cases by establishing that third-party payors as 
well as physicians may be held liable for negligence. As 
new cases arise, the traditional elements of negligent 
malpractice claims may require reinterpretation in the 
context of changed provider-patient and third-party- 
payor settings. 

There is little to suggest any shift in the physician’s 
legal and fiduciary duty to act in the best interests of his 
patient by utilizing all available resources according to 
accepted medical standards. Increasingly, national med- 
ical standards, rather than local customs, have been 
adopted as the legal test. 6 These standards include no 
provisions for consideration of nonmedical factors, such 
as service restrictions imposed by third party-payors. 
However, as the influence of nationally pervasive cost- 
containment strategies effects patterns of practice, 
standards of care may evolve that will reflect the realities 
of resource limitations. Traditional notions of a unitary 
medical standard of care may then be replaced by re- 
source-based classifications, with particularly onerous 
consequences for the poor. 

An aspect of due care suggested by the court concerns 
the appropriate response by a physician to a denial of 
preauthorizations of services by the third-party payor. 
How exhaustive must an appeal on behalf of the patient 
be to insulate the physician from liability? What are the 
physician’s duties to the patient when a vigorous appeal 
is rejected? 

According to the California court, third-party payors 
may be held liable when requests for services are “arbi- 
trarily ignored” or “unreasonably disregarded or over- 
ridden.” Public policy favoring cost-containment may 
encourage future courts to define “arbitrariness” and 
“unreasonableness” narrowly, requiring evidence of gross 
negligence or recklessness in the design and implementa- 
tion of the process for reviewing requests and appeals 
before finding payor liability. 7 

A related issue not explicitly discussed in the case is the 
matter of informed consent. The fiduciary relationship 
created between physician and patient is the basis for the 
ethical and legal principles underlying the informed con- 
sent doctrine. The modern view requires disclosure of 
information that a reasonable patient would consider 
material to arriving at an informed decision about medi- 
cal care, including risks and alternatives. 8 Applying this 
“materiality” test may require discussions with patients 
about the range of available options based on services 
their payor will preauthorize, the associated risks and 
alternatives, the physician’s best medical judgement 
according to accepted standards of care, and any finan- 
cial interest the physician may have that might be adverse 
to the patient. 



Potential hospital liability was another area not ad- 
dressed in this case. Cost-containment strategies, pro- 
spective payment systems and contracts with third-party 
payors create powerful incentives for hospitals to con- 
strain resource utilization. At the same time, it has been 
recognized that hospitals have independent duties of care 
to patients . 9 Although not a party in the Wickline case, 
one can envision situations in which shared physician- 
hospital liability might apply. 

The law moves relatively slowly compared to the 
rapidly changing environment in which medicine is prac- 
ticed. Long-standing legal principles may fit awkwardly 
with new health care formats. Although some commen- 
tators have proposed that under certain circumstances 
cost-containment factors be accepted as a malpractice 
defense , 10 prevailing legal principles do not permit bal- 
ancing of conflicts between financial considerations and 
good patient care. 

In an amicus curiae brief filed in the Wickline case, the 
California Medical Association expressed concern that 
“physicians not be placed between the proverbial rock 
and hard place. If the third-party payor imposing these 
controls is permitted to avoid liability by maintaining the 
fiction that the mechanisms have only fiscal consequen- 
ces, so that patient care is solely the physician’s responsi- 
bility, the physician becomes the insurer. If rationing 
malfunctions, the physician who complies with the pro- 

gram is liable to the patient. If the physician does not 
comply, the physician is punished or faces responsibility 
for incurring unauthorized costs .” 11 

The result in the Wickline case, while alerting payors 
to their potential liability, has not made the physician’s 
position any less precarious. 


1. Wickline v State of California Cal Rpt. 1986;228:661. 

2. Levey S, Hess DD: Bottom line health care? N Engl J Med 

3. Reagan MD: Physicians as gatekeepers. A complex challenge. N 
Engl J Med 1987;317:1731-34. 

4. Capron QM: Containing health care costs: Ethical and legal impli- 
cations of changes in the methods of paying physicians. Case West 
Reserve Law Rev 1986;36:708. 

5. Carlova J: A jury merges a $500,000 haymaker on health bureau- 
crats. Med Econ 1987;60:80-85. 

6. Eisner MJ: Current development in the law: Malpractice and 
informed consent. Conn Med 1985;49:595-600. 

7. Macauley RC Jr: Health care cost containment and medical mal- 
practice: On a collision course. Suffolk Univ Law Rev 1987; 

8. Eisner MJ, Tilson JQ, Agsten MA: A primer on informed consent 
for Connecticut physicians. Conn Med 1986;50:391-98. 

9. Reed PA: Expanding theories of hospital liability: A review. J 
Health & Hosp Law 1988;21:217-29. 

10. Morreim EH: Cost constraints as malpractice defense. Hastings 
Cent Rep 1988;18:5-10. 

1 1. Cited in Schanz SI: Wickline v State of California: Closing the 
door on third party liability? Tort Insurance Law J 1987;22:331-35. 

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Description: Yohimbine is a 3a-15a-20B-17a-hydroxy Yohimbine-1 6a-car- 
boxylic acid methyl ester. The alkaloid is found in Rubaceae and related trees. 
Also in Rauwolfia Serpentina (L) Benth. Yohimbine is an indolalkylamine 
alkaloid with chemical similarity to reserpine. It is a crystalline powder, 
odorless. Each compressed tablet contains (1/12 gr.) 5.4 mg of Yohimbine 

Action: Yohimbine blocks presynaptic alpha-2 adrenergic receptors. Its 
action on peripheral blood vessels resembles that of reserpine, though it is 
weaker and of short duration. Yohimbine's peripheral autonomic nervous 
system effect is to increase parasympathetic (cholinergic) and decrease 
sympathetic (adrenergic) activity, ft is to be noted that in male sexual 
performance, erection is linked to cholinergic activity and to alpha-2 ad- 
renergic blockade which may theoretically result in increased penile inflow, 
decreased penile outflow or both. 

Yohimbine exerts a stimulating action on the mood and may increase 
anxiety. Such actions have not been adequately studied or related to dosage 
although they appear to require high doses of the drug . Yohimbine has a mild 
anti-diuretic action, probably via stimulation of hypothalmic centers and 
release of posterior pituitary hormone. 

Reportedly, Yohimbine exerts no significant influence on cardiac stimula- 
tion and other effects mediated by B-adrenergic receptors, its effect on blood 
pressure, if any, would be to lower it; however no adequate studies are at hand 
to quantitate this effect in terms of Yohimbine dosage. 

Indications: Yocon® is indicated as a sympathicolytic and mydriatric. It may 
have activity as an aphrodisiac. 

Contraindications: Renal diseases, and patient s sensitive to the drug. In 
view of the limited and inadequate information at hand, no precise tabulation 
can be offered of additional contraindications. 

Warning: Generally, this drug is not proposed for use in females and certainly 
must not be used during pregnancy. Neither is this drug proposed for use in 
pediatric, geriatric or cardio-renal patients with gastric or duodenal ulcer 
history. Nor should it be used in conjunction with mood-modifying drugs 
such as antidepressants, or in psychiatric patients in general. 

Adverse Reactions: Yohimbine readily penetrates the (CNS) and produces a 
complex pattern of responses in lower doses than required to produce periph- 
eral a-adrenergic blockade. These include, anti-diuresis, a general picture of 
central excitation including elevation of blood pressure and heart rate, in- 
creased motor activity, irritability and tremor. Sweating, nausea and vomiting 
are common after parenteral administration of the drug. 1 2 Also dizziness, 
headache, skin flushing reported when used orally. 13 
Dosage and Administration: Experimental dosage reported in treatment of 
erectile impotence. 1 - 3 > 4 1 tablet (5.4 mg) 3 times a day, to adult males taken 
orally. Occasional side effects reported with this dosage are nausea, dizziness 
or nervousness. In the event of side effects dosage to be reduced to Vz tablet 3 
times a day, followed by gradual increases to 1 tablet 3 times a day. Reported 
therapy not more than 10 weeks. 3 
How Supplied: Oral tablets of Yocon® 1/12 gr. 5.4 mg in 
bottles of 100’s NOC 53159-001-01 and 1000’s NDC 


1. A. Morales et al. , New England Journal of Medi- 
cine: 1221 . November 12, 1981 . 

2. Goodman, Gilman — The Pharmacological basis 
of Therapeutics 6th ed.,p. 176-188. 

McMillan December Rev. 1/85. 

3. Weekly Urological Clinical letter, 27:2, July 4, 


4. A. Morales et al . , The Journal of Urology 1 28: 

45-47, 1982. 

Rev. 1/85 




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CSMS-1988: The Society’s Year in Review 


C MIC, the physician-owned and directed professional liability insurance company founded by CSMS in 1984, 
ended its fourth account year with invested assets of $90 million, and 2,400 members. 

• Following a meeting with the Connecticut Insurance Department, M.D. Enterprises of Connecticut (MDEC) has 
completed capitalization arrangements to maintain the Department’s $1 million reserve requirement for HMO’s, 
while providing sufficient capital to bring M.D. Health Plan to breakeven. The MDEC arrangements include funds 
raised from the Company’s second stock offering completed on 12-3 1-88, as well as from CSMS-IPA, Inc. MDEC is 
the 100% physician-owned holding company founded by CSMS in 1987. 

• M.D. Health Plan begins 1989 with 12,000 HMO enrollees. In addition, MDEC’s innovative, employer-funded 
joint venture with Stirling and Stirling, Inc. now has some 4000 enrollees. These combined programs, it is anticipated, 
will generate in excess of 100,000 patient visits and $12 million in physician fees in 1989 for CSMS-IPA members. 

• A prominent plaintiffs attorney has paid $99,000 to a 
Waterbury cardiologist in settlement of the physician’s 
countersuit against him alleging that earlier litigation 
against the doctor, withdrawn after weeks of trial and 
adverse publicity, was groundless. 

• The Connecticut Supreme Court handed CSMS a 
victory over incursions into the practice of medicine by 
limited-license practitioners, by rejecting podiatry’s defi- 
nition of ‘Toot” as including the ankle. 

• The CSMS Medicare Courtesy Card, although highly 
successful as a voluntary Society program and widely 
imitated in other states, became a mandatory state pro- 
gram in the final minutes of the 1988 session of the state 
legislature. Its $19,500/ $24,000 income limits, however, 
were retained intact, thus keeping the program based on 
need. This was of some consolation, at least, given the 
political feeding frenzy in process as the clock approach- 
ed midnight of the final day of the election-year session. 

• Connecticut’s AM A Delegation grew again, to five 
CSMS delegates and five alternates, thanks to still in- 
creasing AM A membership among the physicians in our 
state. CSMS membership also reached a new high. 

• CHIS, the new CSMS-sponsored buying service for 
physicians, added medical waste disposal to its growing 
list of supplies and services provided at volume discounts. 

• Another new CSMS membership benefit, the Dodson 

ROBERT J. BRUNELL, M.A., Director of Scientific Activities, 
Connecticut State Medical Society. 

Workman’s Compensation Insurance Program, began 
offering coverage this year, featuring a remarkable and 
substantial annual dividend program based on favorable 

• The new CSMS Hospital Medical Staff Section, re- 
presenting some thirty-two hospital medical staffs, held 
its first Annual Meeting in the spring, and its bylaws were 
approved by the Society’s House of Delegates in the fall. 
CSMS-HMSS was represented by its president at the 
national AMA-HMSS meeting in December. 

• A photography contractor is now at work taking por- 
traits of all CSMS members, so that the Society’s 1989- 
90 “Medical Directory of Connecticut” will be a pictorial 
directory. It has become the major referral source in our 
state, and is a real benefit to CSMS members. 

• The CSMS Physician Health protocol was signed by 
Society and State Department of Health Services offi- 
cials this year, to service the needs of physicians in the 
five small county medical associations. The larger Fair- 
field, Hartford, and New Haven county associations 
already have their own state-approved impaired physi- 
cian programs in operation. 

• The Council has authorized the appointment of a 
special CSMS Bicentennial Committee to plan the obser- 
vance of the Society’s 200th anniversary in 1992. A copy 
of a 1942 CSMS historical publication, The Heritage of 
Connecticut Medicine , is being sought. Hardbound in 
red cloth, it was published in observance of the Society’s 
sesquicentennial anniversary. 

VOLUME 53, NO. 1 







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Reye’s Syndrome 

The paper by Eagel et al in this issue of Connecticut 
Medicine 1 reports an additional case of Reye’s syndrome 
in an adult. This syndrome, first described by Reye et al 2 
in 1963, has been reported from time to time in adults 
since at least 1979. 3 The oldest individual reported with 
Reye’s was 59 years old, and 20 more cases have been 
reported in individuals age 16 and above. While there has 
been an overall decline in the incidence of Reye’s syn- 
drome from 0.47 cases per 100,000 in 1981 to 0.16 per 
100,000 in 1986, most of the decrease has occurred 
among individuals less than ten years of age. The reasons 
for this decline are unclear but have been attributed in 
part to reduction in aspirin use. 4 In 1986, 38% of patients 
with Reye’s syndrome were under 4 years of age, 12% 5 
to 9 years, 34% 10 to 14 years, 15% 15 to 19 years, and 
only 2% older than 20 years. 5 

With the increasing earlier recognition of this syn- 
drome, and with improved treatment, the fatality rate 
has dropped from 41% in 1974 to 27% as of 1986. 5 
During the period of time that Reye’s syndrome has been 
observed there has been a demonstrated close associa- 
tion with three prodromal viral illnesses: influenzas A or 
B, or primary varicella virus infection. Less frequently 
the syndrome has been associated with other viruses 
(reovirus, Coxsackie virus, echovirus, parainfluenza, 
polio, and adenovirus) or premonitory syndromes (acute 
respiratory or gastrointestinal illness). 

A variety of other epidemiologic factors has been 
noticed since Reye’s syndrome was first described. 6 These 
include the possibility of a genetic predisposition to the 
syndrome in that Reye’s seems to occur occasionally 
among siblings. Also toxins such as allantoin, aflatoxin, 
pesticides, and environmental pollutants have been con- 
sidered as potential contributing causal factors. It is an 
interesting fact that Reye’s syndrome has now been con- 
vincingly demonstrated to be more frequent among indi- 
viduals who have used salicylates. In a study of Reye’s 
syndrome among patients who were matched with class- 
mates who had experienced similar antecedent respira- 
tory illnesses, patients and controls were similar except 
for the fact that patients more frequently had fever and 
had used salicylates. 

Mitochondrial injury has been noted to be a substan- 
tial factor in Reye’s syndrome and elevations of aspartate 
and alanine aminotransferase have been noted to be 

Editorials are expressions of personal opinion and do not necessarily 
reflect the policies of CSMS. 

Connecticut Medicine does not hold itself responsible for statements 
made by any contributor. 

characteristic of the syndrome. Abnormalities have been 
noted in the urea cycle, and hyperammonemia in Reye’s 
syndrome apparently results from the fact that ornithine 
transcarbamylase is reduced making it difficult to detox- 
ify ammonia load. 7 ’ 8 More recently medium chain 
acyl-CoA dehydrogenase has been noted to be decreased 
in asymptomatic siblings of children dying of both sud- 
den infant death syndrome and a Reye’s-like syndrome. 
The later finding introduces the possibility that some 
individuals presenting with Reye’s syndrome might have 
an enzymatic deficiency that could be treated if it were 
recognized in advance. 

It is possible that patients with Reye’s syndrome may 
have impaired pathways for metabolizing salicylates. 9 A 
variety of metabolic disorders have been suggested as 
etiologic factors, and there are a number of syndromes 
that can simulate Reye’s syndrome including salicylism, 
propionic aciduria, methylmalonic aciduria, systemic 
carnitine deficiency, and hydroxymethylglutaric aciduria. 

The Center for Disease Control definition for Reye’s 
syndrome specifies: 1. An acute noninflammatory en- 
cephalopathy documented by alteration in the level of 
consciousness with the cerebrospinal fluid containing 
eight or fewer leukocytes per mm 3 or histologic sections 
of the brain demonstrating cerebral edema without peri- 
vascular meningeal inflammation; 2. Hepatic disease 
documented by biopsy or autopsy, or by a threefold or 
greater rise in levels of either serum glutamic oxaloacetic 
transaminase (SGOT), serum glutamic pyruvic transam- 
inase (SGPT), or serum ammonia; 3. No other reason- 
able explanation for cerebral or hepatic abnormalities. 

The present report by Eagel et al on Reye’s syndrome 
in an adult is of importance in that it stimulates interest 
and discussion about Reye’s syndrome in individuals 
beyond the younger pediatric age groups where the syn- 
drome was first noticed. As more and more cases are 
reported it is clear that the syndrome can occur in older 
individuals. Moreover it is clear that there is a tremen- 
dous problem with overlap between this syndrome and a 
variety of other metabolic syndromes that can simulate 
Reye’s syndrome. Much work needs to be done to dem- 
onstrate potential underlying metabolic abnormalities in 
individuals who are identified as having Reye’s syn- 
drome. Some of these are well known metabolic dis- 
orders; others are not. The exact relationship of Reye’s to 
various documented metabolic conditions remains un- 
clear. As yet there has been no convincing demonstration 
of a single metabolic disorder consistently present in this 

With respect to the present case report by Eagel et al, it 
should be emphasized that Reye’s syndrome is a diagno- 

VOLUME 53, NO. 1 


sis of exclusion: one has to suspect other disorders first. 
Significant factors relative to liver disease include the 
acetaminophen ingestion, the use of chlorpromazine in 
the past, as well as the use of salicylates. All of these 
agents can cause liver pathology and complicate our 
understanding of this report. The Center for Disease 
Control definition of Reye’s is most adequate during 
times of peak influenza activity. At other times this 
simple definition is problematic. In a recent discussion 
with Dr. Eugene S. Hurwitz 10 at the Center for Disease 
Control, Dr. Hurwitz emphasized that in reports of 
Reye’s syndrome there is an increasing need to exclude 
the various metabolic diseases which can simulate Reye’s. 
Furthermore, he emphasized that at this time he consid- 
ers light microscopy no longer fully satisfactory to de- 
lineate Reye’s syndrome and that electron microscopy 
should be performed if at all possible to confirm Reye’s. 
Reye’s remains a complex and enigmatic syndrome where 
some of the pieces have been identified (exposure to a 
virus and aspirin), but where other pieces remain to be 
found (the possibility of an underlying metabolic ab- 
normality) before this reaction pattern can be thoroughly 

David P. Johnson, M.D. 

Middletown, CT 


1. Eagel B, Vinoski B, Krugman D: Reye’s syndrome in an Adult . 
Conn Med , 1988;..:...-... 

2. Reye RDK, Morgan G, Baral J: Encephalopathy and fatty degen- 
eration of the vicera: A disease entity of childhood. Lancet 

3. Atkins JN, Haponik EF: Reye’s syndrome in the adult patient. Am 
J Med 1979;67:672-78. 

4. Arrowsmith JB, Kennedy DL, Kwitsky JN, et al: National pat- 
terns of aspirin use and Reye syndrome reporting. United States, 
1980 to 1985. Pediatrics 1987;79:858-63. 

5. Reye Syndrome Surveillance-United States, 1986. MMWR 
1987;36:(No 41):689-91. 

6. La M ontagne J R: Summary of a workshop on disease mechanisms 
and prospects for prevention of Reye’s syndrome. J Infect Dis 

7. Snodgrass PJ, DeLong GR: Urea cycle enzyme deficiencies and an 
increased nitrogen load producing hyperammonemia in Reye’s 
syndrome. N Engl J Med 1976;294:855-60. 

8. Brown T, Hug G, Lansky L, et al: Transiently reduced activity of 
carbamyl phosphate synthetase and ornithine transcarbamylase in 
liver of children with Reye’s syndrome. N Engl J Med 1976; 

9. Roe CR, Millington DS, Maltby D, et al: Recognition of medium 
chain acyl-Co A dehydrogenase deficiency in asymptomatic siblings 
of children dying of sudden infant death or Reye-like syndrome. 
J Pediatr 1986;108:13-18. 

10. Hurwitz, Eugene S: Reye’s office. Center for Disease Control, 
Atlanta, GA., Personal Communication, 29 August 1988. 

Letter to the Editor 

Letters to the Editor are considered for publication (subject to 
editing and abridgment), provided that they are submitted in 
duplicate, signed by all authors, typewritten in double spacing, and 
do not exceed V / 2 pages of text (excluding references). They should 
not duplicate similar material being submitted or published else- 
where. Letters referring to a recent Journal article should be 
received within six weeks of the article’s publication. 


To the Editor: As the physician consultant to the 
Division of Hospital and Medical Care in the Depart- 
ment of Health Services of the State of Connecticut, I 
regularly visit hospitals in Connecticut as part of a licen- 
sure team. My recent (the past three years) focus has 
been the processes of review of appointment and reap- 
pointment processes for members of the medical staff. I 
am writing to alert your readers to a type of letter of 
reference that I have recently seen. It is unacceptable 
insofar as it does not allow the governing body of any 
hospital to exercise a meaningful, rational control of the 
privileges of its medical staff. The relevant section of the 
Public Health Code is Sec. 19-13-D3 (c) (1) (A). 

I am enclosing, verbatim, the letters. I have removed 
identifiers although I saw the originals and they were 
from two different Connecticut physicians in two differ- 
ent Connecticut hospitals. They were part of the appoint- 
ment folder of a physician applying to the staff of yet 
another, ie, third, Connecticut hospital. 

Letter 1 

“....This letter is in reference to your request for 

information regarding Dr. — . Dr. worked 

as an emergency physician on a part-time basis from 
January 198- until August 198-. Officially, his privi- 
leges were temporary staff in the Department of 
[Emergency Medicine]. There were no grievances or 
complaints filed with any medical staff committee or 

other body of the institution during his time at 

Hospital. Dr. performed well as a member of 

the Department of [Emergency Medicine] during this 
time. He requested that his privileges be discontinued 
because of his other professional commitments. 

We appreciated his service to the hospital. 

Please do not hesitate to contact me if I can be of any 
further assistance. 

“....In response to your letter of 198- regard- 
ing the affiliation of Dr. was appointed part 

time emergency room physician on 198- by 

the [Governing Body] of Hospital. He resigned 



in the middle of 198-. Dr. still has temporary 

privileges here, but has not been actively employed 
here for a year. 

There were no complaints or grievances filed against 
Dr. or any complaints relating to his compe- 

tency, nor any restrictions of his license or privileges, 

while at Hospital. While affiliated here, we 

have no knowledge of any privileges at any other 
health institution. 

I trust this will assist you in the credentialing of Dr. 

. If I may be of further assistance, please do not 

hesitate to contact me.” 

A letter of this nature is unacceptable in fulfilling the 
role of a letter of reference for two reasons. First of all, it 
does not allow any governing body to control privileges 
unless it appoints Dr. X but then grants him no privi- 
leges! There is no information about Dr. X’s particular 
skills, limitations, character, or performance while at 
these hospitals (other than the blanket statement that he 
performed “well” in letter 1). Secondly, this type of letter 
would, if the other letters of reference were identical, 
cause the hospital to be in violation of its own medical 
staff bylaws in every one of the 41 hospitals I’ve visited 
over the past three years. This is so since every hospital’s 
medical staff bylaws has a paragraph describing qualifi- 
cations for membership. In this descriptive and norma- 
tive section the usual stipulations refer to “good reputa- 
tion, demonstrated competence,” etc. Letters like the 
ones above address none of these qualifications and raise 
the very real question whether the hospital’s governing 
body can fulfill its obligation — given such a paucity of 
data — of controlling privileges in a meaningful way. 

These letters are relatively worthless. They merely attest 
to the absence of deleterious information about Dr. X. 
As important as that information is, that could have 
been said in one sentence, thereby avoiding the self- 
protective format of such empty letters. If what one 
wants is merely the affirmation of “no grievances” etc., 
one can get this information from an administrator. 
What one wants from a medical peer is medical informa- 
tion, ie, the applicant’s skills, weaknesses, interpersonal 
relations, etc. Ideally, the author of a letter of reference 
should address those privileges being requested at the 
applicant’s hospital; however, this information is, unfor- 
tunately, often not provided the author. 

Additionally, for whatever reason(s) the authors of 
these letters made them so scanty, they damn the appli- 
cant with their faint praise. Any credentials committee 
member who sees such a letter ought immediately to 
entertain at least two thoughts — either the author hasn’t 
the skill to write a worthwhile letter of reference, or the 
author hasn’t the inclination to write one since there is 
not much to say or, worse, there is something to hide. If 
the hospital requires three letters of reference and receives 
two like these, it needs two more of the worthwhile type. 
These count for very little. 

I urge hospitals and physicians alike to consider the 
letter of reference an indispensable part of the processes 
of granting of appointments and privileges. Such letters 
need to be honest, as fair as possible to all the parties, and 
complete. Most of all, they need to be complete. Omit- 
ting important information is, at its best, not helpful. At 
its worst it is dishonest. 

Richard M. Ratzan, M.D. 
University of Connecticut Health Center 
Farmington, CT 


To the Editor: Now is the time for action. The new 
President will face tough choices when he is forced to 
deal with Medicare, long-term care coverage, mandatory 
assignment, uninsured employees and related consumer- 
driven health issues. No one, however, is at greater risk 
from these decisions than we physicians are. 

We will bear the result of any manipulation of the 
system and its subsequent impact, direct or indirect, on 
the high quality of care we strive to deliver. If we do not 
now, each of us, take a more active role as informed 
citizens, our fate will be decided for us. Experts are now 
predicting that the next eight years will shape the face of 
medicine in this country for the coming three decades. 

Physicians must not believe gullibly that one or two of 
us active in the “political” side of medicine will be 
enough. All of us must speak out. Politics is now creep- 
ing not only into reimbursement issues, but into quality 
of care concerns, limitations of hospital access, choice of 
physicians, and drug prescribing practices. 

Many of the policymakers in the new administration 
will be lawyers with financial management backgrounds. 
They cannot rightfully be blamed for developing policy 
decisions that seem irrational to us physicians, if those 
with medical expertise have failed to assist, or even to 
challenge them. As a physician, you are a far better 
patient advocate than they or anyone else. 

Please don’t wait for an engraved invitation, either. 
Government leaders need to hear what you have to say 
when it counts. Don’t think that the AM A or your State 
Medical Society lobbyists can “take care of the problem” 
without your active participation and support. Their 
calls for action need a prompt response from you. 

Do write to your elected leaders politely and suc- 
cinctly, with your ideas and possible solutions, not just 
complaints. Offer to serve as “informal” advisors to poli- 
cymakers in your state and in Washington. Volunteer to 
speak to senior citizen groups, including AARP, on the 

VOLUME 53, NO. 1 


physician view of current health care controversies, and 
work together with seniors on issues where common 
ground can be established. Get involved and give your 
input to medical society committees that deal with these’ 

Perhaps our public image would improve dramati- 
cally if we were seen sacrificing some of our own limited 
free time to become more involved in helping formulate 
logical health care policies to benefit our patients. The 
“politicization” of medical care will continue in this 
country with or without our involvement. At least we 
could help write some of the rules we will be expected to 

Andrew D. Weinberg, M.D. 

Branford, CT 


Diagnostic Nuclear Medicine. 

2nd Edition. Editors: A. Gottschalk, P.B. Hoffer, E.J. 
Potchen. Williams & Wilkins. Baltimore. 1988. xli + 537 
pages + 28 page index in volume 1; xxiii + 617 pages + 
repeat index in volume 2, $215.00. 

That nuclear medicine remains a useful modality in 
medical diagnosis, even after the advent of both com- 
puted tomography and magnetic resonance imaging, is a 
fact borne out by the appearance of the second edition of 
this portion of Golden’s Diagnostic Radiology. How- 
ever, the change in the content of nuclear medicine’s 
contributions is best shown by the wise decision to elimi- 
nate the chapter on speculating on the future that ap- 
peared in edition one. The passage of 12 years has been 
marked by the decline of the “brain scan” that depended 
upon leakage across the blood brain barrier, while en- 
tirely new areas have evolved, such as applications in 
cardiology and the advent of neuroreceptor imaging. 

Seventy-five chapters cover nearly all of the diagnostic 
areas of nuclear medicine, as well as a few therapeutic 
applications (as in hyperthyroidism and thyroid carci- 
noma). There are approximately 125 contributors to 
these two volumes (and hence this reviewer’s small chap- 
ter should not produce a conflict in an objective evalua- 
tion). Initial chapters cover the history of nuclear medi- 
cine, decision making, physics and instrumentation, and 
radiopharmaceuticals plus radiation dosimetry. The clin- 
ical chapters lead off with the cardiovascular system. 
Indeed, this is the largest section (about 296 pages in 16 
separate chapters). Other large sections deal with neu- 
rology (156 pages), gastroenterology (150 pages), and 
bone (66 pages plus 19 on bone-marrow imaging in the 

section on hematology). Some chapters have applicabil- 
ity in several sections. For example, a discussion of 
receptor-site imaging (chapter 54) is placed in the section 
on endocrinology; there are multiple applications to cen- 
tral nervous system imaging. 

Monoclonal antibodies are mentioned on several 
pages, but there is no clear discussion of bone densitome- 
try (either radionuclide or X-ray source of the beam). 
With the word “Diagnostic ...” in the title of the volumes, 
it is perhaps understandable that more was not done with 
other therapeutic uses of internally-administered radio- 
pharmaceuticals. Pediatric aspects are covered in chap- 
ter 24 (cardiovascular) and chapter 66 (specific problems 
in children), with multiple references in other sections. 
Positron emission tomography is discussed in three prin- 
cipal sections; again there are references to the technique 
scattered throughout other chapters. 

These are handsome and substantial volumes which 
stand as the next step in the evolution of nuclear medi- 
cine (the three-volume text on nuclear medicine edited by 
Freeman and Johnson had appeared in 1984-86). There 
are contributions by a good cross section of the nuclear 
medicine community (physicists, radiopharmacists, tech- 
nologists, and physicians in specialty areas as well as 
those in nuclear medicine). Typographical errors appear 
few in number (on the contents page chapter 1 starts on 
page 1 , not page 3 as stated, and Lang should be Lange). 

For the expert in the field, or the physician who makes 
frequent referrals to nuclear medicine, these two volumes 
will stand as a useful guide to the present state of the field 
(and a reference point for following the advances of the 

Richard P. Spencer, M.D., Ph.D 
University of Connecticut School of Medicine 
Farmington, CT 


Members of the Connecticut State Medical Society 
reading papers before other organizations are requested 
to submit their papers to the JOURNAL for considera- 
tion by the Board of Editors for publication. Authors 
preparing manuscripts for submission to Connecticut 
Medicine should consult INFORMATION FOR 
AUTHORS. This material may be obtained from the Jour- 
nal office. Adherance to the instructions will prevent 
delays both in acceptance and in publication. 

Please send them to: 

Robert U. Massey, M.D., Editor 
Connecticut Medicine 
160 St. Ronan Street 
New Haven, Connecticut 06511 
(203) 865-0587 



The President’s Page 

The 1989 Legislature and Us 

By the time you read this, the 1989 Connecticut State Legislature 
will have convened what promises to be a trying session for 
organized medicine. We have prepared with a legislative forum 
held in October, and a well-attended dinner for county association 
and specialty section presidents in November. These programs 
have turned up a group of activist physicians who can address 
issues which need support at the Capitol. 

The potential number of problem issues is awesome and still 
grows weekly. I’ve been called to be on a panel discussing univer- 
sal health care, and the papers phone for my comments on 
whether chiropractors should or should not be allowed hospital 
privileges. Dr. Roger Beck, your CSMS President-Elect, has been 
present at many task force meetings attempting to resolve the nurse prescriptive authority issue, 
and a similar issue for physician’s assistants waits in the wings. Our old friends — tort reform, 
Medicare assignment, triplicate prescriptions and direct patient access to physical therapists — 
will not go away. Whatever energy is left is devoted to positive issues — toxic waste control, 
tobacco and alcohol related bills, a nuclear freeze, state supported fitness programs. There are 
others I haven’t named, and surely some not yet recognized as issues. 

The make-up of the state legislature has changed little. As a whole it has followed the federal 
lead in reviewing medicine as a business rather than as a profession. Economic issues take 
precedence so that arguments for controlling health care costs are stronger than those which 
point out a declining standard of health care in Connecticut. I feel we must make it very clear to 
the legislature that passage of many of the bills being considered would lead to a lower level of 
care for the patients. 

Even the noun denoting the person we are caring for has lost a nuance of professionalism and 
has been replaced by one connoting a business relationship. The dictionary defines patient as 
“one under medical treatment” and client as “one for whom professional services are being 
rendered.” While the latter is formally correct, it gives a sterile and unfriendly ring to the 
relationship in my view. I believe this attitude underlies much of our present inability to 
convince legislators of the physician’s special status as the patient’s prime advocate, with our 
certified and long training at the medical school and postgraduate level. Giving any increased 
patient responsibility to limited license or unlicensed practitioners without showing additional 
and equivalent certified medical training is a decrease in the overall quality of health care in 

Resisting these legislative pressures is not taking anything away from those non-MD’s who 
want hospital privileges or direct access to patients, or prescriptive privileges, when they didn’t 
have such responsibilities in the past, or any increase in certifiable medical training to warrant 
the change. Giving non-medical personnel those responsibilities would also add a layer of cost to 
an already overburdened health care system, but I believe the professional argument is much 
more important. 

Our task will be to convince the legislators of the importance of their role in maintaining 
current good medical standards, rather than to risk diminishing the quality of health care in our 

Norman A. Zlotsky, M.D. 


VOLUME 53, NO. 1 





** . ~ATURSS 






For information call: Robert Donnell Productions 233-3654 or 1-800-243-9774 



Reflections on Medicine 

Emil von Behring and Diphtheria 

A memory from medical school days that still can 
elicit a sense of dread is that of diphtheria. I recall 
standing, masked and gowned, at the foot of a narrow 
bed watching an emergency tracheotomy performed on 
a “mummied” nine-year-old. I knew that I could never 
do this, that here was the line that divided the real 
doctors from the pretenders, and that now was the time 
to quit while quitting was still possible. Too much for 
head, heart, and hands to learn, and I was probably not 
genetically or culturally equipped to practice medicine; 
after all, as far as I knew, none in my family had been a 
physician, maybe for good reasons. 

Everything about diphtheria had seemed daunting; 
my own shots of toxin-antitoxin had left a peculiarly 
vivid memory. I am sure the TAT followed the bad news 
of a positive Schick. I have a picture-clear memory of our 
next door family doctor carefully injecting Schick toxin 
intradermally using an elegant, tiny gold needle which he 
had just boiled in a spoon over the flame of our gas stove. 
I recall the red spot on my arm that lasted for days and 
then peeled. A negative Schick, of course, was required 
for admission to kindergarten. 

Mortality from diphtheria was high even after the 
general use of antitoxin. At the Herman Kiefer Hospital, 
the infectious disease hospital in Detroit, overall mortal- 
ity from diphtheria between 1927 and 1936 was 12.1%, 
but a little over half the patients had had the mild, 
tonsillar type. One-fourth of the cases had nasopharyn- 
geal diphtheria and that carried a 30.4% mortality. 
Hemorrhagic diphtheria, 1 .2% of the total, carried a 97% 
mortality. This was all under nearly ideal conditions and 
with the proper use of antitoxin. Of course many patients 
were admitted after several days of croup or sore throat 
during which no one wanted to think about diphtheria. 
Prognosis depended on the day of the disease when the 
antitoxin was first given. And the antitoxin was not 
without serious risk; serum sensitivity had to be checked 
for and sometimes the patient desensitized. The epin- 
ephrine syringe was always at hand. 

ROBERT U. MASSEY, M.D., Professor, Division of Humanistic 
Studies in Medicine, Department of Community Medicine and Health 
Care, University of Connecticut School of Medicine, Farmington, CT. 

If you’ve read Sinclair Lewis’s Arrowsmith you may 
remember Martin’s terrifying night in the farmhouse 
with the little eight-year-old Mary Novak. 

“He had to make a decision, irrevocable, perhaps 
perilous. He would use diphtheria antitoxin. But cer- 
tainly he could not obtain it from Pete Yeska’s in 

There followed the wild drive in the old Ford to get the 
antitoxin, the return, the intravenous injection, then 
“There was a gurgle, a struggle in which her face black- 
ened, and she was still. ... Slowly the Novaks began to 
glower, ... Slowly they knew the child was gone.” And 
then, as he was driving home through the night, “‘I shall 
never practice medicine again,’ he reflected.” 

It was just a hundred years ago this year that Emil von 
Behring left the Prussian army to begin his work as an 
assistant to Koch in the Institute of Infectious Diseases in 
Berlin. Klebs and Loeffler had identified the bacillus of 
diphtheria five years earlier, Roux and Yersin at the 
Pasteur Institute had demonstrated that a sterile filtrate 
from a diptheria bacillus culture would produce the 
symptoms of the disease in animals, and in 1890 Fraen- 
kel and Brieger demonstrated that this bacillus-free 
“toxalbumin” injected into guinea pigs would induce 
immunity to C. diphtheriae. Within days of the report, 
von Behring had shown that an animal injected with 
immune serum resisted infection, and an animal with the 
disease if treated with immune serum could be cured. 

The first use of antitoxin in a child with diphtheria was 
on Christmas night, 1891, in von Bergmann’s clinic in 
Berlin. In 1913 von Behring introduced his toxin-anti- 
toxin mixture for active immunization, but immuniza- 
tion programs were not the rule in North America until 
the 1920s. Since then mortality rates have fallen from 20 
per 100,000 to less than .006. 

Emil von Behring shared the Nobel prize with Emile 
Roux in 1901; his name was among those of the 93 
German intellectuals who signed the manifesto against 
the 1914 war. He died of pneumonia at Marburg, 31 
March 1917. Antiserum for that disease, which would 
cut mortality in half, was still a decade or so away. 

VOLUME 53, NO. 1 


1911 - 1988 

Frederick C. Weber, Jr., M.D., of Athens, Vermont, formerly of Greenwich, died on 15 September 1988 
while vacationing in Alaska. He had celebrated his 77th birthday on 12 July just prior to leaving for a fishing 
expedition. Cause of death was respiratory failure. 

Dr. Weber had retired from the practice of internal medicine in 1986 and moved to Vermont with his wife, 
Janette Frissell Weber. 

In 1971-72, Dr. Weber served as president of the Connecticut State Medical Society. In addition to being a 
member of the AMA, he had served on numerous committees of both the State Society and the Fairfield 
County Medical Association. He had been a delegate to the CSMS House of Delegates until his move to 

Dr. Weber served the profession in many capacities. In 1958-59 he was president of the Greenwich Medical 
Society; in 1965-66 he assumed the responsibility as president of the Fairfield County Medical Association. He 
was a CSMS associate councilor, 1963-64; CSMS secretary, 1968-69; vice president, 1969-70; and president 
elect, 1970-71. 

From 1954 to 1960, Dr. Weber was a member of the Board of Health for the town of Greenwich. 

Born the son of a physician in Washington, D.C., Dr. Weber received his undergraduate degree from Yale 
University in 1932. He completed his medical degree in 1936 at Johns Hopkins University School of Medicine; 
he was a member of both Phi Beta Kappa and Alpha Omega Alpha. He served his internship at Johns Hopkins 
from 1936 to 1937 and was an assistant resident in medicine at New York Hospital from 1937 to 1940, after 
which he opened his practice in Greenwich. From 1940 to 1942 and again from 1946 to 1950 he was an 
instructor in medicine at Cornell Medical School. He was board certified in internal medicine in 1943. 

During World War II, Dr. Weber was a Lieutenant Colonel in the U.S. Army Medical Corps, serving in the 
southwest Pacific region. 

Upon his return to Connecticut in 1946, Dr. Weber took an active leadership role at Greenwich Hospital, 
and served as director of the department of medicine from 1954 to 1960. In 1952 he was designated a fellow of 
the American College of Physicians. 

He was appointed by the governor to the Connecticut State Medical Examining Board. He also devoted 
many hours to peer review at both the county and state level. 

In his quiet manner, Dr. Weber was always concerned for his patients, his family and the standards of his 
chosen profession. Throughout his fifty years as a physician, he served as a mentor to many young physicians 
who trained under him. 

Since retiring to an early-American farmhouse in an idyllic Vermont setting, Dr. Weber had excavated an 
old pond, had the dam rebuilt and stocked the pond with brook and rainbow trout. More recently he was in the 
process of rehabilitating an apple orchard. 

Dr. Weber enjoyed the outdoors as a hunter and fisherman. He and Mrs. Weber had planned to do some 
salmon fishing in Alaska at the time of his death. 

His survivors include his wife, two daughters, Susan Weber Plass of Sparta, New Jersey, and Sally N. Weber 
of Los Angeles, California; a son, Stephen L. Weber of Athens, Vermont; and a brother, Richard R. Weber of 
Scarsdale, New York. 

P.H.M. and L.R.T. 




The McConnell Case and the “Death with Dignity Statute” 

Joseph M. Healey, J.D. 

T he McConnell case focuses attention on Connect- 
icut’s “Death with Dignity Statute” 1 and its im- 
plications for decisions at the end of life. This is the first 
case involving the statute to be reviewed by the Connect- 
icut Supreme Court and two important questions are 
raised : ( 1 ) whether the statute requires that nonterminal 
patients be forced to accept artificial nutrition and 
hydration in all cases; (2) whether the statute so con- 
strued violates the constitutional rights of patients. The 
Connecticut Supreme Court has the opportunity to clar- 
ify these questions and to address the legal boundaries of 
this important area of public policy. Many Connecticut 
physicians hope that the Court will act decisively to 
provide such a clarification of their rights and responsi- 
bilities. ' 

The first question involves issues of statutory con- 
struction. Determining the meaning of any statute can be 
a complicated process involving an after-the-fact ac- 
knowledgement of the intent of its proponents, recogni- 
tion of the effect of amendments, and reconciliation of 
the perceptions of those who supported and opposed the 
legislation. Such complications are especially present in 
clarifying the meaning of the “Death with Dignity” 

This bill was the product of negotiations and com- 
promises which make it difficult to conclude that there is 
a single, clear meaning which reconciles its conflicting 
provisions and purposes. What is in most states a patient 
rights statute, which describes the circumstances under 
which a currently competent patient may direct how care 
is provided should future incompetence prevent active 
participation in his or her self-determination, has become 
in Connecticut a physician and hospital immunity stat- 
ute which describes how to avoid civil and criminal 
liability if a patient’s wishes are followed. This reluctant 
acceptance of a patient’s right to execute a living will is 
further diminished by a provision allowing the next of 
kin to veto the expressed wishes of the patient. 

There is an inherent conflict between the overall goal 
of the legislation — the facilitation of patient self-deter- 
mination — and 4he amendments to the proposal which 

JOSEPH M. HEALEY, J.D., Associate Professor, Department of 
Community Medicine and Health Care, University of Connecticut 
School of Medicine, Farmington, CT. 

undermine the patient’s right to self-determination. This 
conflict is further evident in the provisions of the statute 
that purport to treat artificial nutrition and hydration in 
a different manner from other forms of medical treat- 
ment. The statute seeks to protect the patient from 
undertreatment, yet pursues this laudable goal in a con- 
fusing and inappropriate manner by failing to distin- 
guish between ordinary nutrition and hydration and 
artificial nutrition and hydration, by excluding nutrition 
and hydration from the definition of “life support sys- 
tem,” and by apparently attempting to require the attend- 
ing physician who does not deem the patient to be in a 
terminal condition to provide nutrition and hydration in 
every circumstance. Such failures to acknowledge that 
there are situations in which artificial nutrition and 
hydration are medical care which may be refused by the 
patient are inconsistent with an overall legislative goal of 
permitting, not restricting the exercise of patient self- 

The second question involves the extent to which the 
state could limit the exercise of a right to refuse treat- 
ment. Even if one finds that the statute on its face pur- 
ports to require patients not in a terminal condition to 
accept nutrition and hydration, such a constraint does 
not appear to be grounded in any of the compelling state 
interests acknowledged by other courts as legitimate 
bases of state regulation. These interests include the 
state’s interest in the preservation of life, the protection 
of third parties, the prevention of suicide, and the ethical 
integrity of the medical profession. Though there may be 
circumstances in which the first and second of these may 
justify some constraint on the individual’s right of self- 
determination, it is difficult to conclude that an adult 
person of sound mind does not have the right to deter- 
mine that he or she does not want to receive medical care 
or treatment of any sort should he or she be in a condi- 
tion such as a persistent vegetable state, with no reasona- 
ble likelihood of regaining cognitive function. Such 
judgment seems clearly within the constitutionally pro- 
tected area of individual self-determination. 

Hopefully, the Supreme Court will affirm the patient’s 
right of self-determination and end whatever confusion 
the “Death with Dignity” statute has caused. 


1. Connecticut General Statutes Sec 19A-570 et seq. 

VOLUME 53, NO. 1 



The Society maintains the Physician Placement Service as a service to the medical profession in Connecticut. 
Opportunities for physicians to locate in Connecticut will be published as space permits and will be distributed 
to physicians making inquiries of such opportunities. Information should be sent to 160 St. Ronan St., New 
Haven, CT 06511 (203-865-0587). 

Physicians wishing to establish practice in Connecticut are invited to submit a resume to be kept on file with 
the Society. An announcement of a physician’s availability will be published in two issues of Connecticut 
Medicine as space permits. 

Listing of physicians in the Placement Service does not in any way represent certification by the Society. 
Investigation of credentials and experience is the responsibility of those seeking applicants for positions. 



Active Allergy Practice in large centrally located Connecticut city with 
large metropolitan population is available for sale. Also a small office 
building suitable for one or two doctors available on a sell or rent basis, 
within easy walking block to hospital or short drive to medical school. 
Reply to CSMS, AL/VG. 


Full-time positions in satellite and main emergency departments of 
JCAH-Approved 380-bed hospital, with residency program. Unique 
combination of emergency and urgent care medicine. Full hospital 
emergency department privileges. Paramedic base stations in both 
facilities. Beautiful shoreline area. Seek EM/FP/IM, BC/BE individ- 
ual, ACLS, ATLS. ER experience preferred. Highly competitive salary 
and benefit package. Excellent work schedule. Contact Gordon Van 
Nes, M.D., Emergency Department, Middlesex Memorial Hospital, 
Crescent St., Middletown, CT 06457. (203) 344-6691. 

Park City Hospital in Bridgeport, CT is seeking full-time Emergency 
Medicine physician. Twenty-six thousand E.R. visits with Industrial 
Medical Center in E.R. Active Paramedic Program. Certification in 
ACLS and experience in Emergency Medicine required. First year 
compensation $96,000 with attractive benefit package. Send current 
CV to: Don Rankin, M.D., Emergency Department, Park City Hospi- 
tal, 695 Park Ave., Bridgeport, CT 06604 or call (203) 579-5040. 


Colchester — BC/BE Family Physician wanted to join busy solo Fam- 
ily Practice. Guaranteed income; good benefits; good coverage and no 
obstetrics. Potential for partnership in two years. Please send CV to: 
Dr. Kassem M. Khybery, 79 Norwich Ave., Colchester, CT 06415. 

Excellent opportunity to join succesful residency trained solo practi- 
tioner on the beautiful Connecticut shoreline. Practice and lifestyle of 
the highest quality in this wonderful family community. Please reply to 
CSMS, c/o FP/UX. 


Practice for sale. One or two Internists or Family Practitioners to 
purchase established, active solo Primary Care practice, South Central 
Connecticut. Stately, spacious offices. Two open staff community 
hospitals close by. Please apply to CSMS, c/o FP/IM. 

Physician wanted for small group practice in Danbury area. Family 
Practice and Internal Medicine. Send CV to CSMS, c/o FP/NP. 


Internist. Board certified. To join three MD Internal Medicine Group 
in coastal Connecticut. To begin July, 1989. Send CV to: William 
Colom, M.D., 447 Montauk Ave., New London, CT 06320. 

The Institute of Living (a 400-bed, private, not for profit, psychiatric 
hospital) is seeking a BC/BE internist subspecialist to join a growing 
medical program with clinical and teaching responsibilities. Research 
opportunities available. Contact Charles Boren, M.D., Medical Direc- 
tor, The Institute of Living, 400 Washington St., Hartford, CT 06106. 


Retired physician’s fully-equipped office, including X-ray, available for 
immediate rental or sale. Excellent location. Please reply: Judith 
Turetsky, 496 West McKinley Ave., Bridgeport, CT 06604. (203) 367- 
9300 for further information. 

Plant Physician. The Pfizer Inc. Chemical Production facility in 
Groton has an immediate need for a Physician to manage the Plant 
Medical Department which consists of seven employees. Duties include: 
Providing industrial health services to a facility of 1,800 employees; 
providing treatment and referral for emergencies and occupational 
illnesses and injuries; developing innovative medical programs to 
address employee health and safety issues; providing support in disabil- 
ity return-to-work program, EAP, and case management. The success- 
ful candidate will have an MD degree and license to practice medicine; 
strong management and interpersonal skills; experience in an industrial 
or military setting a plus. We offer an excellent compensation and 
benefits package. Please send your resume in confidence with salary 
requirements to: Mr. Barton S. Finegan, Director of Employee and 
Community Relations, Pfizer, Inc., Eastern Point Rd., Groton, CT 
06340. EOE. 


Recently trained, solo, OB/GYN, Board Certified seeks BE/BC asso- 
ciate for busy private practice in a beautiful resort community in 
southern Connecticut. Excellent opportunities for higher education, 
water recreation, | and shopping. Easy access to New York City, 
Boston, Hartford and Cape Cod. Very stable economy with low 
unemployment. Would consider two physicians relocating together. 
Please forward CV to: Stanley P. Solinsky, M.D., 350 Montauk Ave., 
New London, CT 06320. 


Ophthalmology Practice. Seeking colleague to assume full responsibil- 
ity soon. Send CV to CSMS, c/o OPH/KN. 




Full or part time associate to join three person pediatric group in a New 
Haven suburb located five miles from Yale-New Haven Medical Cen- 
ter. Earnings will be 50% of gross income. Call 248-4846 any evening 
after 7 P.M. 


Wanted — Psychiatrist to share office space three days weekly. Fair- 
field, CT. 259-6787. 


Board certified or board eligible radiologist to join a hospital and 
multi-office group practice in North Central Connecticut. Applicant 
should be competent in all imaging modalities including CT and MRI. 
Training in interventional radiology is desirable but not essential. 
Salary first year leading to full partnership. J. Danigelis, M.D., 151 
Berle Rd., South Windsor, CT 06074. 



Presently available. Age 61. Licensed in Connecticut. Nat’l bds. AB 
cert., (SURG). MD, Columbia University, New York, NY; Int. and 
Res., Hartford Hospital. Interested in institutional position involving 
primary care and/or utilization management. Prefers central Connec- 
ticut area. Occupational physician for 12 years with a major corpora- 
tion. Write, Peyton H. Mead, M.D., 2 Mead Lane, Balbrae, Bloom- 
field, CT 06002. 


July ’89. Age 35. Presently in practice. AB cert. MD, Boston Univer- 
sity, Boston, MA; Int. and Res. Carney Hospital, Boston, MA. Prefers 
group type practice in a medium to large-sized community. Write, Eric 
C. Hatton, M.D., 800 Rosewood Dr., Clovis, NM 88101. 

Cardiology. Sept. ’88. Age 34. Licensed in Connecticut. Nat’l bds. AB 
elig. MD, Instituto Technologico de Santo Domingo, Dominican 
Republic; Res., Salvador B. Gautier Hospital, Santo Domaingo; Fel- 
lowship, Metropolitan Hospital Center, NY Medical College, NY, NY. 
Prefers any type practice in a small to medium-sized community. 
Write, Sergio R. Collado, M.D., 301 Post Rd., East, Apt. 19, West- 
port, CT 068800. 

Cardiology. Dec. ’89. Age 32. Flex. AB cert. MD, Government Medi- 
cal College, Surat, India; Int., Detroit Macomb Hospital Corp., 
Detroit, MI: Res. and Fellowship, St. Joseph Mercy Hospital, Pontiac, 
MI; Prefers solo or associate type practice in a small to medium-sized 
community. Write, Mukeshchandra M. Patel, M.D., 900 East Blvd. 
South, Apt. F-124, Pontiac, MI 48053. 

Gastroenterology. July ’89. Age 28. Nat’l bds. AB elig. MD, Mount 
Sinai School of Medicine, NY, NY: Int. and Res., Long Island Jewish 
Medical Center, New Hyde Park, NY; Fellowship, Booth Memorial 
Medical Center, Flushing, NY. Prefers solo, group or assoicate type 
practice. Write, Jeffrey T. Dreznick, M.D., 63-53 Haring St., Apt 608, 
Rego Park, NY 11374. 

Gastroenterology and Nutrition. July ’89. Age 35. Nat’l bds. AB elig. 
D.O. College of Osteopathic Medicine and Surgery, Des Moines, I A; 
Int., Oakland General Osteopathic Hospital, Madison Heights, MI; 
Res., Henry Ford Hospital, Detroit, MI; Fellowship, Wayne State 
University, Detroit and Providence Hospital, Southfield, MI (Gast); 
University of California, David Medical Center, Sacramento (Nutr.). 
Prefers group, associate type practice in a large-sized community. 
Write, Curtis Freedland, D.O., 25601 Briar Dr., Oak Park, MI 48237. 

Hemotology/ Oncology. Oct. ’89. Age 31. Nat’l bds. AB cert. (IM); AB 
elig. (Hm/On). MD, Vanderbilt University, Nashville, TN: Int., Res., 
and Fellowship, Oklahoma University, Oklahoma City, OK. Prefers 
group, associate, institutional or solo type practice. Write, Richard J. 
Conklin, M.D., 244 Barrett Place, Edmond, OK 73034. 


July ’89. Age 33. Nat’l bds. AB elig. Int., Res. and Fellowship, Univer- 
sity of Pittsburgh, Pittsburgh, PA. Prefers group type practice in a 
medium to large-sized community. Write, Paul D. Fischer, M.D., 301 
Woodbridge Dr., Pittsburgh, PA 15237. 


INTERNIST— NEW HAVEN, CT-CHCP a pre-paid, staff model 
HMO with over 70,000 members is seeking BE/BC Internists for 
positions currently available and for those openings which will start 
within the next year. Affiliations with prestigious institutions such as 
Yale New Haven Hosital enable our staff to provide high quality 
medical care while offering opportunities to maintain clinical skillls in 
the setting of an established HMO. Highly competitive compensation 
package. Send CV along with salary requirements in confidence to: 
Mr. D.J. Lenhart, CHCP PERSONNEL, 221 Whitney Ave., New 
Haven, CT 06511. Equal Opportunity Employer, M/F. 

HISTORIC FAIR HAVEN SECTION of New Haven. 700 sq. ft. 
office. Formerly internist satellite office. No physician in area now. 
Family dentist in building. 865-1668. 

$60.00 for 25 words or less; $1.00 for each 
additional word. Payable in advance. 

VOLUME 53, NO. 1 







^fe Me^ v ° 


Bellevue Hospital Center 

Week Emergency 
Board Review 
4:30-7:30 PM 

Designed to enable registrants to review essential 
material in preparation for the WRITTEN PORTION 
The ACEP Comprehensive Study Guide will be used 
by faculty as the basis for lecture outline content. 

Also, arrangements can be made for each registrant 
to take a TWO-HOUR " 1-ON-l PATIENT MANAGE- 
MENT ENCOUNTER SESSION " that simulates & 
prepares them for the ORAL PORTION (Part II) of the 

Accreditation: 60 AMA Cat. 1 Credit Hrs. Tuition $1575 

Approved for 60 Hrs. ACEP Credit 

Info, available on upcoming courses & tutorial: 

#315 EM/Two Track Course - 6/12-16,1989 
#329 EM Board Rev. Course - 10/16-20,1989 
#312 EM Tutorial (by arrangement) 

Call or Write: (212) 340-5295/ 24 hour service 

NYU Post-Graduate Medical School 

550 First Ave., NY, NY 100.16 CM t/89 

MATERIAL printed in Connecticut Medicine, the Journal of the 
Connecticut State Medical Society, is covered by copyright. Written 
permission must be obtained before reproducing, in part or in whole, 
any material published in Connecticut Medicine. 

Connecticut Medicine does not hold itself responsible for statements 
made by any contributor. 

PROSPECTIVE authors preparing manuscripts for submission to 
Connecticut Medicine should consult “Information for Authors.” This 
material may be obtained from the Journal office. The manuscript, 
including references, should be typed double spaced; all material, 
including figures, should be submitted in duplicate. The transmittal 
letter should designate one author as correspondent and include his 
complete address and telephone number. 

MANUSCRIPTS should be submitted to the Editor, Robert U. 
Massey, M.D., Connecticut Medicine , 160 St. Ronan St., New Haven, 
CT. 065 1 1 . Manuscripts are received with the explicit understanding 
that they are not simultaneously under consideration by any other 

ALTHOUGH all advertising material is expected to conform to 
ethical medical standards, acceptance does not imply endorsement by 
this journal. 

REPRINTS are available at an established schedule of costs. A 
reprint rate and order form is sent to the author with his page proofs. 

SUBSCRIPTION RATE: The subscription price per year for mem- 
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ADDRESS editorial and business correspondence to: 

Connecticut Medicine , 160 St. Ronan St., New Haven, CT. 065 1 1. Tel. 
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CONNECTICUT MEDICINE is the official publication of the 
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ganized for scientific and educational purposes, published monthly for 
members of the Connecticut State Medical Society. 



There are no known contraindications to the use of sucralfate. 


Duodenal ulcer is a chronic, recurrent disease. While short-term treatment 
with sucralfate can result in complete healing of the ulcer, a successful course 
of treatment with sucralfate should not be expected to alter the post-healing 
frequency or severity of duodenal ulceration. 

Drug Interactions: Animal studies have shown that simultaneous admin- 
istration of CARAFATE (sucralfate) with tetracycline, phenytoin, digoxin, or 
cimetidine will result in a statistically significant reduction in the bioavailability 
of these agents. The bioavailability of these agents may be restored simply by 
separating the administration of these agents from that of CARAFATE by two 
hours. This interaction appears to be nonsystemic in origin, presumably result- 
ing from these agents being bound by CARAFATE in the gastrointestinal tract. 
The clinical significance of these animal studies is yet to be defined. However, 
because of the potential of CARAFATE to alter the absorption of some drugs 
from the gastrointestinal tract the separate administration of CARAFATE from 
that of other agents should be considered when alterations in bioavailability 
are felt to be critical for concomitantly administered drugs. 

Carcinogenesis, Mutagenesis, Impairment of Fertility: Chronic oral 
toxicity studies of 24 months' duration were conducted in mice and rats at 
doses up to 1 gm/kg (12 times the human dose). There was no evidence of 
drug-related tumorigenicity. A reproduction study in rats at doses up to 38 
times the human dose did not reveal any indication of fertility impairment. 
Mutagenicity studies were not conducted. 

Pregnancy: Teratogenic effects. Pregnancy Category B. Teratogenicity 
studies have been performed in mice, rats, and rabbits at doses up to 50 times 
the human dose and have revealed no evidence of harm to the fetus due to 
sucralfate. There are, however, no adequate and well-controlled studies in 
pregnant women. Because animal reproduction studies are not always pre- 
dictive of human response, this drug should be used during pregnancy only if 
clearly needed. 

Nursing Mothers: It is not known whether this drug is excreted in 
human milk. Because many drugs are excreted in human milk, caution should 
be exercised when sucralfate is administered to a nursing woman. 

Pediatric Use: Safety and effectiveness in children have not been 


Adverse reactions to sucralfate in clinical trials were minor and only rarely led 
to discontinuation of the drug. In studies involving over 2,500 patients treated 
with sucralfate, adverse effects were reported in 121 (4.7%). 

Constipation was the most frequent complaint (2.2%). Other adverse effects, 
reported in no more than one of every 350 patients, were diarrhea, nausea, 
gastric discomfort indigestion, dry mouth, rash, pruritus, back pain, dizziness, 
sleepiness, and vertigo. 


There is no experience in humans with overdosage. Acute oral toxicity studies 
in animals, however, using doses up to 1 2 gm/kg body weight could not find a 
lethal dose. Risks associated with overdosage should, therefore, be minimal. 


The recommended adult oral dosage for duodenal ulcer is 1 gm four times a 
day on an empty stomach. 

Antacids may be prescribed as needed for relief of pain but should not be 
taken within one-half hour before or after sucralfate. 

While healing with sucralfate may occur during the first week or two, 
treatment should be continued for 4 to 8 weeks unless healing has been 
demonstrated by x-ray or endoscopic examination. 


CARAFATE (sucralfate) 1-gm tablets are supplied in bottles of 100 (NDC 
0088-1712-47) and in Unit Dose Identification Paks of 100 (NDC 0088- 1712-49). 
Light pink scored oblong tablets are embossed with CARAFATE on one side 
and 1712 bracketed by C's on the other Issued 1/87 


1 . Eliakim R, Ophir M, Rachmilewitz D: J Clin Gastroenterol 1987;9(4):395-399. 


Another patient benefit product from 







Effect of Aerobic Training on Left Ventricular Diastolic Filling 


ABSTRACT— The effects of aerobic training on left 
ventricular diastolic filling were determined and related 
to the effects on maximal oxygen uptake, left ventricular 
systolic function, and left ventricular mass. Nine un- 
trained healthy males with a mean age of 32 years 
underwent a ten-week program of bicycle training. Echo- 
cardiographic left ventricular mass, maximal oxygen 
uptake, radionuclide-derived left ventricular ejection frac- 
tion, and average left ventricular filling rate were obtained 
before and after training. Training resulted in significant 
increases in maximal oxygen uptake (from 30±6 (mean ± 
S.D.) to 40±7 ml/kg/min, p<0.001) and average left 
ventricular filling rate (from 2.04±0.36 to 2.22±0.31 end- 
diastolic volumes/sec, p<0.05), but no changes in heart 
rate, systolic blood pressure, left ventricular ejection 
fraction, or left ventricular mass. These data indicate that 
short-term high-intensity aerobic training enhances av- 
erage left ventricular diastolic filling independent of any 
change in left ventricular geometry, systolic function, 
heart rate, or blood pressure. 


T HE functional and morphological cardiac responses 
to endurance training include an increase in max- 
imal oxygen uptake (V0 2 max), a lowering of the resting 
heart rate, and increases in left ventricular cavity dimen- 
sions and/or wall thickness. * 1 Training-induced resting 
bradycardia with its attendant prolonged diastolic filling 
partly explains the resulting cardiac dilation. Since rest- 
ing cardiac output is unaltered by training, stroke volume 
must increase to compensate for the lower heart rate. 

DALE G. SENIOR, M.D., Assistant Professor of Medicine, Uni- 
versity of Wisconsin, Madison, WI; formerly Clinical Research Fel- 
low, Section of Cardiology, Department of Medicine, Mt. Sinai Hospi- 
tal. KAREN L. WATERS, R.N., M.S., Clinical Coordinator of 
Research/ Clinical Nurse Specialist, Section of Cardiology, Depart- 
ment of Medicine, Mt. Sinai Hospital. MARK CASSIDY, R.P.T., 
Administrator for Pulmonary and Neurology Services, Mt. Sinai Hos- 
pital. TOM CRUCITTI, B.S., C.N.M.T., Acting Vice-President of 
Operations, Scientific Imaging, Farmington, CT: formerly, Supervisor 
of Nuclear Medicine, Department of Radiology, Mt. Sinai Hospital. 

I HOWARD SHAPIRO, M.D., Director of Nuclear Medicine Section, 
Department of Radiology, Mt. Sinai Hospital. ARTHUR L. RIBA, 
M.D., Director of Cardiology Section, Department of Medicine, Mt. 
Sinai Hospital; Associate Professor of Medicine, University of Con- 
necticut School of Medicine, Farmington, CT. Reprint requests: Mount 
Sinai Hospital, 500 Blue Hills Ave., Hartford, CT 061 12 (Dr. Riba). 

Training-induced cardiac enlargement serves as the pre- 
dominant factor underlying the increase in stroke volume 
since ejection phase indices are relatively unaffected, but 
additional cardiac adaptations may also be important. 1 

Recently, interest has focused on left ventricular dia- 
stolic function in athletes. Diastolic filling and ventricu- 
lar stiffness have been found to be normal or facilitated 
in endurance-trained subjects with physiological hyper- 
trophy 2-6 which is in marked contrast to patients with 
pathological hypertrophy. 7-11 Enhanced left ventricular 
diastolic filling has also been demonstrated in athletes 
during exercise 12 and this may serve as an additional 
cardiac adaptation contributing to the increased stroke 
volume seen after endurance training. However, very 
little is known about the direct effects of training on 
diastolic function. 13 The purpose of this study is to eval- 
uate the effects of short-term aerobic training on left 
ventricular diastolic filling. 

Materials and Methods 
Subject Selection : 

Nine healthy male volunteers aged 29-35 years with- 
out clinical evidence of heart disease were recruited from 
the hospital staff. None of the subjects had participated 
in endurance training for the past six months and none 
had been exercising for more than two hours per week. 
All subjects gave informed written consent and the 
experimental protocol was approved by the Human 
Research Review Committee of Mount Sinai Hospital. 
The physical characteristics of the subjects are summar- 
ized in Table 1 . All subjects were tested for the following 
variables before and after their training program: 
Estimation of Body Fat: 

Six skinfold sites (chest, triceps, subscapular, abdo- 
men, suprailiac, thigh) were measured in triplicate with a 
Lange caliper and the averages of each of the six mea- 
surements were summed for each subject. The height and 
weight of each subject were recorded. The skinfold data 
collected from these sites were used to estimate body fat 
according to a modification 14 of the Jackson and Pollock 
equation. 15 Lean body mass was determined by subtract- 
ing fat weight from the total body weight. 

M-mode echocardiograms were obtained at rest by a 

VOLUME 53, NO. 2 


single experienced technician using standard techniques. 
Using the Penn Convention, 16 posterior wall thickness, 
interventricular septal thickness, and left ventricular in- 
ternal dimension at end-diastole were determined and 
averaged over several cardiac cycles. To minimize the 
variability in echocardiographic measurements, echocar- 
diograms were coded and read blindly by one of us (AR) 
without knowledge of subject identity or training status. 
Left ventricular mass was calculated by the method of 
Devereaux and Reicheck 16 and derived measurements 
were indexed to body surface area. 

Maximal Oxygen Uptake: 

All subjects underwent cardiopulmonary exercise test- 
ing prior to and after completion of their conditioning 
program. The exercise test protocol was to pedal an 
electronic Mijnhardt KEM-2 Cycle-Ergometer against a 
continuous 30 watt/ minute ramp until exhaustion. Max- 
imal oxygen uptake was determined using a model 
MG A 1 100 Perkin-Elmer mass spectrometer for analysis 
of oxygen fractions of expired air and a Hans Rudolph 
pneumotachograph for gas volume measurement inter- 
faced with a Medical Graphics Corporation model 2000 
wave-form analyzer and Tektronix 4052 A computer for 
data gathering and analysis. Oxygen consumption was 
determined on a breath-by-breath basis continuously 
during the exercise protocol. Subjects were exercised to 
exhaustion, and the highest value was taken as peak 
oxygen uptake. 

Radionuclide Studies: 

Left ventricular diastolic function was determined by 
gated equilibrium radionuclide ventriculography at rest. 
Each subject’s red blood cells were labeled with 20- 
30mCi of Tc-99m pertechnetate after a standard injec- 
tion of stannous pyrophosphate. All radionuclide studies 
were obtained in the modified left anterior oblique pro- 
jection by a single experienced technologist using an 
updated Searle PhoGamma/HP gamma camera inter- 
faced with a Technicare MCS 560 computer. Generation 
of time-activity curves and calculation of left ventricular 
ejection fractions were made by an operator-dependent 
variable left ventricular region of interest after spatial 
and temporal smoothing of the data using a conven- 
tional software program (MICA - Technicare Corp.). 
The analysis was performed without knowledge of sub- 
ject identity or training status. Average left ventricular 
filling rates, in counts per second, were derived by the 
least squares fit techniques using the rapid diastolic por- 
tion of the time-activity curve (CURFIT - Technicare 
Corp.) as validated and applied by Smith et al 10 and in a 
manner similar to that of Lee et al. 17 Values were then 
normalized for the number of left ventricular counts at 
end-diastole and expressed as end-diastolic volumes per 
second (EDV/sec). 

Training Program: 

The subjects trained intensely for ten weeks on an 
upright bicycle ergometer 45 minutes per day, four days 
per week. Each session consisted of a five-minute warm- 
up period followed by 30 minutes of pedaling at work- 
loads adjusted to maintain a minimum of 80% of the 
subject’s maximal heart rate determined on the pre- 

training cardiopulmonary stress test. Each conditioning 
session was followed by ten minutes of cool-down. The 
exercise sessions were monitored on a weekly basis by 
one of the study investigators to assure compliance with 
the exercise protocol, and a log of maintenance target 
heart rates was recorded by each of the subjects. 

Other Measurements: 

Heart rates were calculated from the average RR 
interval taken from a several-minute interval during the 
radionuclide study. Three resting upright blood pres- 
sures were recorded and averaged. Body surface area was 
determined by standard means. 

Statistical Analysis: 

Means and standard deviations of pre- and posttrain- 
ing measurements were computed; differences between 
mean values were analyzed by use of a paired t-test for 
correlated samples. Statistical significance was defined 
as P<0.05. 


Adaptations to Training: 

Changes in Maximal Oxygen Uptake: The training pro- 
gram resulted in a significant increase in maximal oxygen 
uptake from 30±6 (mean ± standard deviation) to 40±7 
ml/ Kg/ min, (p<0.001) (Table I). The resting heart rates 
and systolic blood pressures were unaltered by the train- 
ing program, and body surface area decreased (Table I). 

Table I 



AGE 32±3 years 



Heart rate 
(beats / min) 

69±1 1 


Systolic blood pressure 



Body Surface Area 


2 02i0.18 + 

Lean body mass 



Maximal 0 2 uptake 
(ml/kg/ min.) 



All values are expressed as the mean ± 1 standard deviation. 
*Not significant; + p<0.01; X p<0.001. 

Changes in Echocardiographic Measurements and De- 
rived Left Ventricular Mass: There was no significant 
change in end-diastolic left ventricular internal dimen- 
sions, posterior wall thickness, or derived left ventricular 
mass after ten weeks of the training program (Table II). 
Changes in Radionuclide Measurements: Average left 
ventricular filling rate increased significantly from a pre- 
training mean of 2.04±0.36 to a posttraining value of 
2.22±0.31 EDV/sec., p<0.05 (Table II, Fig. 1). In these 
subjects, eight of nine (89%) increased their average left 
ventricular filling rate after training. Examples of time- 
activity curves pre- and posttraining for a representative 
subject are shown in Figure 2. Systolic function as mea- 
sured by the left ventricular ejection fraction did not 
change after training. 


This study evaluated the effects of short-term high 



LVFRav (EDV/sec) 

Table II 


LVEDDI (cm/ m^) 





PWThI (cm/m 2 ) 



LVMI (g/m 2 ) 

88± 15 


LVEF (%) 



LVFR av (EDV/sec) 



All values are expressed as the mean ± 1 standard deviation. *Not 
significant; +p<0.05. LVEDDI=left ventricular end-diastolic dimen- 
sion index; PWThI= posterior wall thickness index; LVMI=left ven- 
tricular mass index; LVEF=left ventricular ejection fraction; LVFR av 
^average left ventricular filling rate. 

3 . 00 — 

2 . 50 — 

2 . 00 — 

1 . 50 — 

1 . 00 — 


Figure 1 

Individual values, mean values, and standard deviations of the average 
left ventricular filling rates (LVFR av ) expressed as end-diastolic 
volumes per second (EDV/sec) pre- and posttraining for the subjects. 

intensity aerobic training on average left ventricular dia- 
stolic filling, heart rate, maximal oxygen uptake, left 
ventricular systolic function, and left ventricular dimen- 
sions and mass. Short-term high intensity aerobic train- 
ing augmented average left ventricular diastolic filling 
and increased maximal oxygen uptake. The increase in 
average left ventricular diastolic filling seen after short- 
term aerobic training occurred without any change in 
resting heart rate, blood pressure, left ventricular systolic 
function, or left ventricular dimension and mass. The 
present findings suggest that enhancement of left ven- 
tricular diastolic filling may be an important functional 
cardiac adaptation to aerobic training. 

Recently, interest has focused on diastolic function in 
athletes with physiologic hypertrophy. Using digitized 
echocardiography, Shapiro and Smith studied the effects 


1 00 


5 0 . . . X . /. 



Figure 2 

Actual radionuclide time-activity curves with computer derived slope 
of the rapid filling phase for a representative subject pre- and postae- 
robic training. Training resulted in an increased average left ventricular 
filling rate (1.63 to 2.19 end-diastolic volumes/ sec) and a slight reduc- 
tion in ejection fraction (65% to 60%). After training, the heart rate 
increased from 58 to 63. 

of six weeks of high intensity running on left ventricular 
structure and diastolic function and noted a 30% increase 
in posterior wall thickness without any detectable changes 
in relaxation or diastolic function. 13 Despite the in- 
crease in maximal oxygen uptake induced by our bicycle 
training program, there was no increase in left ventricu- 
lar dimensions or mass after ten weeks of training, but 
average left ventricular diastolic filling improved signifi- 
cantly. Differences in the subjects studied, type, inten- 
sity, and frequency of the training programs and metho- 
dology used to determine left ventricular diastolic filling 
properties may explain the variability in the results. 
We 2 and others 3-6 have also shown that high endurance 
athletes with physiological hypertrophy have normal 
diastolic function and ventricular stiffness which is in 
contrast to the findings in patients with pathological left 
ventricular hypertrophy associated with left ventricular 
pressure overload. 7-11 In our previous study, there was a 
slight but insignificant trend for average filling rates to be 
higher in the athletes with a greater left ventricular mass 
index. 2 Doppler assessment of the ratio of early-to-late 
peak diastolic velocities suggests enhanced function in 
ultraendurance trained triathletes. 5 In another group of 
aerobically-trained athletes, Matsuda et al found that 
echocardiographically determined left ventricular early 
diastolic filling was enhanced both at rest and during 
exercise compared to sedentary healthy subjects. 12 These 
findings demonstrate that left ventricular hypertrophy 
by itself is not associated with impaired diastolic function 
and as suggested by the present study and those pre- 
viously cited, chronic and short-term aerobic training 
may improve diastolic performance. Enhanced diastolic 
filling may facilitate the trained heart to increase stroke 
volume at rapid heart rates when the diastolic filling 
period is shortened, as occurs during exercise. 

In this study, we used average left ventricular filling 
rate as an index of left ventricular diastolic function. 
Average left ventricular filling rates have been used reli- 
ably to compare diastolic function in patients with path- 
ologic 10 and physiologic 2 hypertrophy with normal sub- 
jects, to assess the effects of antihypertensive therapy on 
the heart, 18 and for the early detection of doxorubicin 

VOLUME 53, NO. 2 


cardiotoxicity. 17 These results are qualitatively similar to 
those obtained using peak diastolic filling rates derived 
by radionuclide techniques 9 and echocardiography. 3 In 
addition, average rapid left ventricular filling rates mea- 
sured with a nonimaging nuclear probe correlate well 
with those calculated with a gamma camera. 10 Use of 
average left ventricular filling rates makes no assumption 
on how the left ventricle fills since all phases of rapid 
diastolic filling are weighted equally. 

Even though our short-term high-intensity aerobic 
exercise program failed to induce physiologic hyper- 
trophy, a significant increase in maximal oxygen uptake 
was elicited, confirming that physiological adaptations 
can precede cardiac morphological changes. Accompany- 
ing the increased maximal oxygen uptake was a signifi- 
cant augmentation of the average left ventricular dia- 
stolic filling rate. Since those factors known to influence 
the rate of left ventricular rapid diastolic filling such as 
age, heart rate, blood pressure, left ventricular volume, 
mass, contractility, and loading condititions 19-22 were 
unaltered by the training program, enhancement of dia- 
stolic filling by aerobic training can be viewed as an 
independent functional myocardial adaptation. Our pre- 
liminary results need to be confirmed in a larger random- 
ized, controlled study using additional methods of eval- 
uating diastolic function. 

Data derived from experimental studies have shed 
some light on the possible mechanisms by which physical 
training facilitates left ventricular diastolic filling. Iso- 
lated hearts from swim-conditioned rats demonstrate a 
more rapid rate of decline of left ventricular pressure 
during diastole compared with hearts from sedentary 
animals. 23 Penpargkul et al have demonstrated enhanced 
calcium uptake and binding in the sarcoplasmic reticular 
vesicles isolated from trained rats. 24 It is speculative that 
enhanced diastolic filling resulting from training may be 
related to an increase in the rate of calcium uptake by the 
sarcoplasmic reticulum of conditioned hearts. Colan et 
al have suggested that relaxation may be facilitated. 3 

In conclusion, short-term high-intensity aerobic train- 
ing augments average left ventricular diastolic filling 
prior to inducing structural cardiac adaptations. En- 
hanced left ventricular diastolic filling may be an impor- 
tant cardiac adaptation underlying the improved cardio- 
vascular fitness of aerobically-trained athletes. The results 
of this study are provocative in terms of a potential 
therapeutic role of physical training in patients with 
diseases characterized by abnormal diastolic filling such 
as coronary artery disease and hypertension. 


The authors gratefully acknowledge the expert techni- 
cal assistance of Jose Ruiz, Dennis Martini, Donna 
Gregory, Kathy Pegolo, and Carole Bartorelli, the secre- 
tarial assistance of Andrea Violette and the thoughtful 
suggestions, advice, and encouragement of Arnold M. 
Katz, M.D. 


1. Schaible TF, Scheuer J: Cardiac adaptations to chronic exercise. 

Prog Cardiovasc Dis 1985;27:297-324. 

2. Granger CB, Karimeddini MK, Smith VE, Shapiro HR, Katz 
AM, Riba AL: Rapid ventricular filling in left ventricular hyper- 
trophy: I. Physiologic Hypertrophy. J Am Coll Cardiol 1985;5: 

3. Colan SD, Sanders SP, MacPherson D, Borow KM: Left ventric- 
ular diastolic function in elite athletes with physiologic cardiac 
hypertrophy. J Am Coll Cardiol 1985;6:545-9. 

4. Finkelhor RS, Hanak U, Bahler RC: Left ventricular filling in 
endurance trained subjects. J Am Coll Cardiol 1986;8:289-93. 

5. Douglas PS, O’Toole ML, Hiller WDB, Reicheck N: Left ventric- 
ular structure and function by echocardiography in ultraendur- 
ance athletes. Am J Cardiol 1986;58:805-9. 

6. Fagard R, Van Den Broeke C, Bielen E, Vanhees L, Armery A: 
Assessment of stiffness of the hypertrophied left ventricle of bicy- 
clists using left ventricular inflow doppler velocimetry. J Am Coll 
Cardiol 1987;9:1250-4. 

7. Hanrath P, Mathey DG, Siegert R, Bleifeld W: Left ventricular 
relaxation and filling pattern in different forms of left ventricular 
hypertrophy: an echocardiographic study. Am J Cardiol 1980;45: 

8. Fouad FM, Slominski M, Tarazi RC: Left ventricular diastolic 
function in hypertension: Relation to left ventricular mass and 
systolic function. J Am Coll Cardiol 1984;3:1500-6. 

9. Inouye I, Massie B, Loge D, Topic N, Silverstein D, Simpson P, 
Tubau J: Abnormal left ventricular filling: an early finding in mild 
to moderate systemic hypertension. Am J Cardiol 1984;53:120-6. 

10. Smith VE, Schulman P, Karimeddini MK, White WB, Merran 
MK, Katz AM: Rapid ventricular filling in left ventricular hyper- 
trophy: II. Pathologic hypertrophy. J Am Coll Cardiol 1985;5: 

11. Bonow R, Rosing DR, Bacharach SL, Green MV, Kent KM, 
Lipson LC, Maron BJ, Leon MB, Epstein SE: Effects of verapamil 
on left ventricular systolic function and diastolic filling in patients 
with hypertrophic cardiomyopathy. Circulation 1981;64:787-96. 

12. Matsuda M, Sugishita Y, Koseki S, Ito I, Akatsuda T, Takamatsu 
K: Effect of exercise on left ventricular diastolic filling in athletes 
and nonathletes. J Appl Physiol 1983;55:323-8. 

13. Shapiro LM, Smith RG: Effect of training on left ventricular 
structure and function. An echocardiographic study. Br Heart J 

14. Golding LA, Myers CR, Sinning WE (eds): The Y’s way to physi- 
cal fitness. Chicago, 1982; pp 69-117. 

15. Jackson AS, Pollock ML: Generalized equations for predicting 
body density of man. Br J Nutr 1978;40:497-504. 

16. Devereux RB, Reichek N: Echocardiographic determination of 
left ventricular mass in man. Circulation 1977;55:613-8. 

17. Lee BH, Goodenday LS, Muswick GJ, Yasnoff WA, Leighton 
RF, Skeel RT: Alterations in left ventricular diastolic function 
with doxorubicin therapy. J Am Coll Cardiol 1987;9:184-8. 

18. Smith VE, White WB, Merran MK, Karimeddini MK: Improved 
left ventricular filling accompanies reduced left ventricular mass 
during therapy of essential hypertension. J Am Coll Cardiol 

19. Brutsaert DL, Housmans PR, Goethals MA: Dual control of 
relaxation. Circ Res 1980;47:637-52. 

20. Grossman W, McLaurin LP: Diastolic properties of the left ventri- 
cle. Ann Intern Med 1976;84:316-26. 

21. Bahler RC, Vrobel TR, Martin P: The relation of heart rate and 
shortening fraction to echocardiographic indexes of left ventricu- 
lar relaxation in normal subjects. J Am Coll Cardiol 1983;2: 

22. Colan SD, Borow KM, Newmann A: Effects of loading conditions 
and contractile state (methoxamine and dobutamine) on left ven- 
tricular early diastolic function in normal subjects. Am J Cardiol 

23. Schaible TF, Scheuer J: Cardiac function in hypertrophied hearts 
from chronically exercised female rats. J Appl Physiol 1981;50: 

24. Penpargkul S, Repke DI, Katz AM, Scheuer J: Effect of physical 
training on calcium transport by rat cardiac sarcoplasmic reticu- 
lum. Circ Res 1977;40:134-8. 



Mobile Mammography: The First Six-Months Experience 

at Mount Sinai Hospital 


ABSTRACT— Mount Sinai Hospital’s Mobile Mam- 
mography Program, BreastCheck, is designed to screen 
large numbers of women for breast cancer in the greater 
Hartford area. Despite the American Cancer Society 
recommendations for screening mammography, many 
physicians still are not complying with these guidelines. 
This report details our first six-months experience. Two 
thousand two hundred thirty women were screened, 38 
women had biopsies, and 14 cancers were detected. The 
overall rate of breast cancer detection is 6.3/1,000 
which compares favorably with the rates from the Na- 
tional Breast Cancer Demonstration Detection Project 
(BCDDP) of 4.6/1,000. 

Underutilization of Mammography 

B REAST cancer is the second most common cancer 
among women. Despite the fact that screening for 
breast cancer has been shown to decrease mortality rates, 
only 5% to 15% of women in the United States have had 
a mammogram. 1 The American Cancer Society (ACS) 
advocates screening for asymptomatic women beginning 
with baseline mammograms at age 35-40, every one to 
two years from age 4(M9, and yearly beginning at age 50. 
“Lack of physician compliance with these guidelines is 
one of the major reasons for underutilization. The high 
cost of the procedure, of $1 10-S220, is the second most 
important factor. Other reasons include lack of patient 
knowledge, and fear of the procedure itself.” 2 
BreastCheck: Procedure 

Mount Sinai Hospital’s mobile mammography ser- 
vice, BreastCheck, addresses several factors affecting 
utilization. Women may be either physician-referred or 
self-referred. If self-referred, the patient must give the 
name of a doctor to whom she wishes the report sent. 
This physician is frequently her primary care physician 
or gynecologist. If the patient has no doctor, she is given 

ELINOR S. KRON, M.D., Attending Radiologist; HAROLD 
MOSKOWITZ, M.D., F.A.C.R., Director of Radiology-Imaging; 
DOROTHY MCCONNER, R.T.R., Mobile Mammography Coordi- 
nator; JULIA ANN LOVELAND, M.A., Mobile Mammography 
Secretary; all from Mount Sinai Hospital, Hartford, CT. 

a list of surgeons to choose from, depending on her 
locale, and compiled with the help of the chiefs of surgery 
at area hospitals and with the consent of each of the 
participating physicians. 

The 34-foot mobile coach was designed to make breast 
cancer screening available in a convenient setting and at 
a low cost. The cost is $55, payable by credit card, check, 
or money order, and, as of 1 October 1988, will be 
covered by most health insurance plans. The coach visits 
shopping areas, health care facilities, school systems, 
corporations, smaller businesses, women’s groups, and 
health fairs. BreastCheck provides free screening exami- 
nations to indigent women one day each month. Appoint- 
ments are made in advance, although walk-in patients 
are accommodated on a space available basis. Patients 
are scheduled fifteen minutes apart. A seven-minute 
videotape on breast self-examination, (BSE), is available 
for viewing. 

Specially trained female radiologic technologists per- 
form the mammogram on a low-dose, state-of-the-art, 
mammography machine. The standard two views of 
each breast, the craniocaudad, and the 45 degree medio- 
lateral oblique view are obtained on the coach. The films 
are batch-processed at the end of the day, and read the 
following morning by radiologists with special training 
and interest in mammography. 

Since this is a screening facility, all demographic data 
are entered on a dedicated computer which permits 
follow-up and statistical analysis. Almost all reports are 
computer-generated. The patient must also sign a con- 
sent form that explains that mammography is only one 
part of the diagnosis of breast disease; that monthly 
breast self-examination and yearly physical examination 
by her physician, as well as following the ACS guidelines, 
constitute important parts of total breast care. 

If the patient’s mammogram is normal, she receives a 
form letter along with the recommendation to follow the 
ACS guidelines, to perform BSE, and to see her physi- 

VOLUME 53, NO. 2 


cian yearly; the patient’s physician receives a computer 
generated report. If the mammogram is abnormal, the 
doctor’s report includes recommendations for biopsy, 
magnification views, ultrasound, or follow-up in six or 
12 month intervals. Likewise, if abnormal, the patient 
receives a letter stating that she should have further 
studies. If a cancer is suspected, the patient receives a 
letter stating that a significant abnormality has been 
detected on her mammogram and that she should arrange 
to see her physician. In addition, her physician is imme- 
diately contacted by telephone. In the cases where a 
cancer is suspected, or when an ultrasound or magnifica- 
tion view is recommended, letters are sent by certified 
mail to both the patient and her physician. 

BreastCheck is designed as a screening facility. Our 
intent is to see large numbers of women, provide mam- 
mograms economically, and determine whether or not 
an abnormality is present. We do not attempt to charac- 
terize an abnormality. 


In the first six months, 11 patients had suspicious 
mammograms. Three of these patients are being fol- 
lowed by a surgeon; the other eight have been diagnosed 
by biopsy to have carcinoma. Another 1 18 patients have 
received the ultrasound or magnification letters which 
resulted in another 30 biopsies. Six more cancers were 
detected after these additional studies, and the other 24 
biopsies were benign. Sixty-two patients were sent letters 
advising six-month follow-ups, and 101 patients were 
advised to return in a year. 

Thus, a total of 14 cancers were detected among 2,230 
women for a rate of 6.3/ 1,000. This figure is higher than 
the figure of 4.6/1,000 that resulted from the National 
Breast Cancer Detection Project, which included the 
screening of 280,000 women. 3 The cancer rate was 14 in 
38 biopsies, or 36%. 

Table 1 compares our experience to the experience at 
Mallinckrodt Institute of Radiology (MIR), Washing- 
ton University in St. Louis: 

Table 1 




Rate/ 1,000 


% Cancers 4 















The total number of recalls and cancers are similar, 
but at MIR almost twice the number of biopsies were 
performed, and almost half the percentage of malignan- 
cies found as compared to BreastCheck. 

Compliance To Screening Among 
Connecticut Women 

Of the 2,230 women screened, 859 or 37% had had a 
previous mammogram as opposed to the national figure 
of 5% to 15% (Table 2). As expected, the lowest age 

group, 35-39, had the lowest percentage of previous 
mammographies, with the incidence of previous mam- 
mography rising with age. Table 3 shows that seven out 
of 14 women, or 50% of those women with positive 
biopsies, had previous mammograms. However, among 

Table 2 

Previous Mammograms 

Age Group 



Total by Age 










































All Ages 







those women with previous mammography, the earlier 
examination had been performed on the average of 7.4 
years ago, with the average age being 64.7 years. Thus, 
while more women in Connecticut are having mammo- 
grams compared to the national average, women are 
clearly not adhering to the intervals for screening set by 
the American Cancer Society. 

Table 3 

Positive Biopsies 

Previous Mammograms No Previous Mammograms 








6 yrs 





3 yrs 





1.5 yrs 





10 yrs 





8 yrs 





3 yrs 





20 yrs 




The Mount Sinai Hospital Mobile Mammography 
program, BreastCheck, has been valuable not only for 
screening large numbers of women for breast cancer, but 
has also increased the awareness of breast disease among 
women. Our rate of cancer detection, 6.3/ 1,000, and our 
percentage of malignancies per total number biopsies, 
36%, demonstrate the effectiveness of our BreastCheck 


1. Fox S, Baum J, Klos DS Tsou CV: Breast cancer screening: the 
underuse of mammography. Radiology 1985;156:607-11. 

2. Survey of physicians’ attitudes and practices in early cancer detec- 
tion. Ca — A Cancer Journal for Clinicians 1985;35:197-213. 

3. Moskowitz M: Breast cancer: age specific growth rates and screen- 
ing strategies. Radiology 1986;161:37-41. 

4. Destouet J and Monsees B: Low-cost breast screening program 
takes to the road in St. Louis. Diagnostic Imaging, June 1987, 



Abstracts by Residents and Fellows 


FOREWORD: The American College of Physicians, Connecticut Chapter, held its annual 
meeting on 21 October 1988 at Danbury Hospital. As part of this program, five prize winning 
abstracts by Associates of the College were selected for presentation. These abstracts, whose first 
authors are medical residents, are printed below. We applaud the support given to the authors by 
members of their teaching faculties. With this, the third collection, we continue an annual 
tradition among the teaching hospitals of our state. 

Jonathan Alexander, M.D., FACP, Scientific Program Committee and Joseph L. Belsky, 
M.D., FACP, ACP Governor for Connecticut, Department of Medicine, Danbury Hospital. 

Cerebellar Venous Infarcts 

WAHID WASSEF, M.D. (Associate), St. Mary’s Hospital, Waterbury 

Cerebellar infarcts are thought of as occurring in the 
elderly, and are usually secondary to vertebral or basilar 
artery thrombosis. Since these vessels also supply the 
brainstem, these types of infarcts are associated with a 
high degree of morbidity and mortality. With the in- 
creasing use of birth control pills, a new type of cerebellar 
infarct is being seen, a cerebellar venous infarct. Although 
it presents in the same manner as a cerebellar arterial 
infarct, if recognized early, the venous infarct can be 
treated and its course can be altered. 

A 28-year-old white female who was taking oral con- 
traceptive pills and had no other risk factors for venous 

thrombosis was diagnosed as having a right cerebellar 
infarct secondary to sigmoid vein thrombosis. Dizziness 
and signs of cerebellar dysfunction progressed to left 
hemiparesis, coma, and respiratory failure. She recov- 
ered in six days with supportive therapy and full anti- 

It is important to consider venous thrombosis in the 
differential diagnosis of a young woman taking birth 
control pills and presenting with signs and symptoms of 
a cerebellar stroke; early institution of heparin may result 
in complete resolution of this otherwise progressive and 
potentially fatal disease. 

Type III Membranoproliferative Glomerulonephritis in Primary Sjogren’s Syndrome 


Greenwich Hospital Association, Greenwich 

Glomerulonephritis (GN) is a rare complication of 
primary Sjogren’s syndrome (PSS). When GN does 
occur, it is usually due to membranous, focal prolifera- 
tive or membranoproliferative lesions. We report for the 
first time the occurrence of Type III membranoprolifera- 
tive glomerulonephritis (MPGN) in association with 
PSS. The patient was a 72-year-old white female with a 
ten-year history of PSS who presented with acute renal 
insufficiency. The patient did not fulfill the diagnostic 
criteria for SLE. Although an ANA was positive at a 
dilution of 1:1,280 in a homogenous pattern, LE prep, 

anti-ds DNA, Sm, and RNP antibodies were negative. 
Anti-SSA (Ro) and anti-SSB (La) antibodies were pres- 
ent. Renal biopsy revealed Type III MPGN, character- 
ized by prominent mesangial cell interposition and both 
subepithelial and subendothelial electron-dense deposits. 

There have been fewer than 20 reported cases of GN in 
PSS, only three of which have been MPGN. We report a 
case of PSS complicated by Type III MPGN, a specific 
type of mesangiocapillary GN never before recognized in 
this setting, and describe a clinical course characterized 
by rapidly progressive renal failure. 

VOLUME 53, NO. 2 


Adult Reye’s Syndrome: Report of a Case* 

Barry Eagel, M.D. (Associate), Bernard Vinoski, M.D. (Associate), and David Krugman, M.D., 

New Britain General Hospital, New Britain 

There have been over 3,500 cases of Reye’s syndrome 
reported to the CDC since 1973. The use of aspirin at the 
time of a prodromal viral illness has been statistically 
associated with the syndrome. Reye’s syndrome presents 
as an acute progressive encephalopathy with varying 
levels of coma and a normal CSF. Hepatic transami- 
nases are elevated, and the AST is usually elevated three 
to 30 times normal. Histological changes seen on liver 
biopsy are characterized by microvesicular intrahepato- 

cyte lipid deposition, which is rarely found in other 

The syndrome has rarely been reported to occur in 
adults older than 18 years. We report the 21st case of 
Reye’s syndrome occurring in an adult, which initially 
presented as acetominophren toxicity but was shown to 
be Reye’s syndrome on histological examination of the 

*Case report published in Connecticut Medicine, January 1989. 

Temporal Arteritis and Autoimmune Thyroid Disease 

JAMSHID SHIRANI, M.D. (Associate), St. Mary’s Hospital, Waterbury 

A 72-year-old white female was seen with headache, 
proximal muscle weakness, and erythrocyte sedimenta- 
tion rate of 130 mm/ hr. She had undergone subtotal 
thyroidectomy for Hashimoto’s thyroiditis 18 years pre- 
viously. She had evidence of frank hypothyroidism, 
impaired vision in right eye, and proximal muscle weak- 
ness mainly involving the shoulders. A right temporal 
artery biopsy was consistent with giant cell arteritis. 
Antithyroglobulin antibodies were present at a titer of 
1:320. Other laboratory findings were as follows: hemo- 
globin, 9.9 mg/dl; alkaline phosphatase, 302 1.U.; GGTP, 
120 1.U.; C3, 131 mg/dl; C4, 83 mg/dl; TSH 50 M IU/ml.; 

T4 3.3 >ulg/ ml. High dose intravenous steroids followed 
by thyroid replacement resulted in rapid recovery of 
vision and weakness as well as decrease in ESR to 30 
mm/ hr after four months. 

Temporal arteritis is associated with circulating im- 
mune complexes. Its association with various autoim- 
mune diseases have been emphasized in the literature. 
Graves’ disease and primary hypothyroidism are pre- 
viously reported in association with temporal arteritis. 
To my knowledge this is the first case of temporal arteri- 
tis reported in a patient with biopsy proven Hashimoto’s 
thyroiditis and circulating antithyroid antibodies. 

Testicular Feminization Presenting in a 78- Year-Old* 


Mount Sinai Hospital, Hartford 

Testicular Feminization Syndrome (TFS) is an inher- 
ited sex-linked recessive disorder characterized by male 
genotype and female phenotype secondary to end-organ 
insensitivity to androgens. The majority of cases present 
before age 30 with inguinal masses or primary amenor- 
rhea or both. 

A 78-year-old phenotypic female underwent an emer- 
gency reduction of an incarcerated right inguinal hernia. 
A mass excised at the tip of the hernia sac revealed 
atrophic testicular tissue with hyalinization of the tubules, 
interstitial fibrosis, Leydig cell hyperplasia, and an epi- 
didymis. The cytogenetics revealed 96% XY, confirming 
the previously unsuspected diagnosis of TFS. The patient 

revealed that as a child she had been treated for hernia, 
and in adolescence she had failed to menstruate. She was 
told by her physicians that she had “female problems.” 
Eleven years prior to this admission she had noticed a 
right inguinal hernia that periodically recurred. 

Ten cases of TFS have been reported in the world 
literature presenting at age 50 or older, with only two 
older than 65. We believe that this patient is the oldest 
reported in the North American literature. Prior to this 
admission her last comprehensive medical evaluation 
had been in 1930, more than two decades before the 
recognition and understanding of TFS. 

*Case report published in Connecticut Medicine, October 1988. 




Important Advances in Clinical Medicine 


The Scientific Board of the California Medical Association presents the following inventory of items of progress 
in pathology. Each item, in the judgment of a panel of knowledgeable physicians, has recently become 
reasonably firmly established, both as to scientific fact and important clinical significance. The items are 
presented in simple epitome and an authoritative reference, both to the item itself and to the subject as a whole, 
is generally given for those who may be unfamiliar with a particular item. The purpose is to assist busy 
practitioners, students, research workers, or scholars to stay abreast of these items of progress in pathology 
that have recently achieved a substantial degree of authoritative acceptance, whether in their own field of 
special interest or another. 

The items of progress listed below were selected by the Advisory Panel to the Section on Pathology of the 
California Medical Association and the summaries were prepared under its direction. 

Platelet Antibodies 

T hrombocytopenia may occur as the sole 
manifestation of disease or may be due to another 
disorder. The management of either primary or second- 
ary thrombocytopenia depends on correctly identifying 
the casual pathophysiologic processes. Over the past 
decade a number of research laboratories have provided 
data to strongly support the hypothesis that primary 
isolated thrombocytopenia in adults — idiopathic throm- 
bocytopenia purpura — is immune-mediated and in many 
cases may be more correctly termed autoimmune throm- 
bocytopenia purpura. The development of sensitive as- 
says that directly measure platelet-associated immuno- 
globulin (PAIg) corroborated earlier studies which sug- 
gested that this disorder is due to the deposition of 
immunoglobulin on the platelet surface, leading to the 
accelerated clearance of sensitized platelets. The ability 
to directly measure PAIg, in contrast to the earlier tests 
for detecting serum antiplatelet factors, has increased the 
sensitivity from 60% to greater than 90% with 93% speci- 
ficity for detecting immune-mediated platelet destruction. 

The increased diagnostic sensitivity has raised new 
questions concerning the specificity of elevated PAIg 
levels. It is now well recognized that increased PAIg can 
occur in thrombocytopenia associated with a wide vari- 
ety of disorders, including systemic lupus erythematosus, 
lymphoma, carcinoma, Hodgkin’s disease, the acquired 
immunodeficiency syndrome, and Hashimoto’s thyroid- 
itis. Elevated PAIg levels also may be associated with 
qualitative platelet dysfunction without concurrent 
Reprinted from The Western Journal of Medicine, November, 1988. 

thrombocytopenia. Thus, elevated PAIg levels are not 
specifically associated with isolated autoimmune or idio- 
pathic thrombocytopenia purpura. In most cases, it is 
unclear whether PAIg noted in either autoimmune throm- 
bocytopenia purpura or the secondary disorders is spe- 
cifically direct against a platelet antigen or is nonspecifi- 
cally deposited on the platelet surface as part of an 
immune complex. In several recent reports the use of 
immunoblot techniques has identified PAIg directed 
against integral platelet proteins in some patients with 
autoimmune thrombocytopenia purpura. A recent study 
using monoclonal reagents for the detection of cell- 
associated immunoglobulin has provided stronger evi- 
dence that the presence of elevated levels of PAIg — more 
than 800 molecules of IgG per platelet — is physiologi- 
cally consistent with currently understood immune-me- 
diated clearance of other blood cells, and this concentra- 
tion of cell-associated immunoglobulin is not observed 
in patients with nonimmune thrombocytopenia. 

Each of the different techniques described to measure 
PAIg requires isolating platelets from whole blood, 
which may be difficult in patients with severe thrombo- 
cytopenia. Newly described fluorescence-activated flow 
cytometric assays and radioactive immunologic assays, 
however, exhibit adequate sensitivity even when few 
platelets are available. Indirect tests may be useful to 
diagnose neonatal isoimmune thrombocytopenia, post- 
transfusion purpura, or transfusion-induced alloimmun- 
ization. Indirect assays for determining suspected drug- 
dependent immune thrombocytopenia have had disap- 
pointing results due to the inability to solubilize drugs 
and do the assays under physiologic conditions. In sum- 

VOLUME 53, NO. 2 


mary, the direct measurement of platelet-associated im- 
munoglobulin is useful in establishing the diagnosis of 
immune-mediated platelet destruction and in choosing 
among various therapeutic alternatives during the course 
of these disorders. 

Laurence Corash, M.D. 

San Francisco 


Court WS, Bozeman JM, Soong S, et al: Platelet surface-bound IgG 
in patients with immune and nonimmune thrombocytopenia. Blood 

Karpatkin S: Autoimmune thrombocytopenia purpura. Blood 

Kelton JG, Powers PJ, Carter CJ: A prospective study of the 
usefulness of the measurement of platelet-associated IgG for the diag- 
nosis of idiopathic thrombocytopenic purpura. Blood 1982;60:1050-3. 

Fine-Needle Aspiration Biopsy of 
Lymph Nodes 

F ine-needle aspiration (fna) or aspira- 
tion biopsy cytology of lymph nodes is done in 
patients presenting with persistent lymphadenopathy for 
which no obvious explanation exists, to stage patients 
with previously diagnosed malignancy (including malig- 
nant lymphoma), and to monitor for recurrence and 
progression of disease. Within this setting, a diagnosis of 
infection, reactive hyperplasia, malignant lymphoma, 
and metastatic tumor is sought. 

The diagnosis of metastatic carcinoma usually is 
straightforward, as is the diagnosis of many reactive, 
inflammatory, and granulomatous disorders. The use of 
lymph node FNA for the primary diagnosis of malignant 
lymphoma has proved more challenging. For this rea- 
son, a confirmatory surgical biopsy is done at most 
hospitals in which a cytologic diagnosis of malignant 
lymphoma has been made or is suspected. This may not 
be necessary in selected cases at centers with broad expe- 
rience in the diagnosis of lymphoproliferative disorders, 
especially when ancillary market studies are available to 
confirm the cytologic interpretation. 

One argument for following lymph node FNA with a 
biopsy is to assess a nodular or diffuse pattern of infiltra- 
tion, a distinction that carries therapeutic and survival 
implications based on the grading system enumerated in 
the National Cancer Institute (NCI) working formula- 
tion for non-Hodgkin’s lymphomas. 

Surgical biopsy must be done in cases of malignant 
lymphoma of predominantly small cleaved cell type 
(poorly differentiated lymphocytic lymphoma) and in 
cases of malignant lymphoma of mixed small cleaved 
and large cell type. Because these lymphomas show a 
spectrum of cell size, they may present a diagnostic 
problem on aspiration biopsy. Furthermore, they are 
classified as either low-grade or intermediate-grade lym- 
phomas based on the biopsy assessment of a nodular or 

diffuse pattern. Malignant lymphoma of small lympho- 
cytic cell type (well-differentiated lymphocytic lympho- 
ma), chronic lymphocytic leukemia, and malignant lym- 
phoma of small lymphocytic-plasmacytoid type are low- 
grade malignant disorders but are difficult to diagnose 
unequivocally without the benefit of biopsy or ancillary 
marker studies. On the other hand, a biopsy would not 
be necessary to grade malignant lymphomas of large cell 
type, which are classified as intermediate grade whether 
nodular or diffuse. Large cell malignant lymphoma; 
malignant lymphoma, immunoblastic (immunoblastic 
sarcoma); malignant lymphoma, lymphoblastic (convo- 
luted and nonconvoluted T-cell lymphoma); and malig- 
nant lymphoma of small noncleaved cells (Burkitf s) are 
all high-grade lymphomas according to the NCI working 
formulation and represent lymphomas that can be diag- 
nosed by fine-needle aspiration. 

Although centers with expertise in hematologic dis- 
orders may not require a confirmatory surgical biopsy in 
the FNA diagnosis of several types of malignant lym- 
phoma, hospitals that have limited experience in this 
discipline should continue to use confirmatory surgical 
biopsy for diagnostic accuracy rather than relying on 
aspiration cytology alone. 

Robert W. Astarita, M.D. 

San Diego 


Das DK, Gupta SK, Pathak IC, et al: Burkitt-type lymphoma — 
Diagnosis by fine needle aspiration cytology. Acta Cytol 1987;31:1-7. 

Kardos TF, Vinson JH, Behm FG, et al: Hodgkin’s disease: Diagno- 
sis by fine-needles aspiration biopsy — Analysis of cytologic criteria 
from a selected series. Am J Clin Pathol 1986;86:286-91. 

Levitt S, Cheng L, Dupuis MH, et al: Fine needle aspiration diagno- 
sis of malignant lymphoma with confirmation by immunoperoxidase 
staining. Acta Cytol (Baltimore) 1985;29:895-902. 

National Cancer Institute sponsored study of classification of non- 
Hodgkin’s lymphomas — Summary and description of a working for- 
mulation for clinical usage. Cancer 1982;49:2112-35. 

Biopsy Findings in Liver 
Transplant Patients 

I N THE PAST FEW YEARS, orthotopic liver trans- 
plantation has become a relatively common therapy 
for a wide variety of both pediatric and adult liver dis- 
eases. Despite improved surgical and immunosuppres- 
sive techniques, patients undergoing this procedure are 
vulnerable to numerous complications involving trans- 
plantation-associated injury to the donor organ, infec- 
tion, exacerbated by immunosuppression, biliary ob- 
struction or leaks, vascular occlusion, and acute and 
chronic rejection. Liver biopsy has been shown to be an 
important adjunct to radiologic and serologic studies in 
these patients and is essential in discriminating between 
rejection and ischemic injury, two of the most common 
causes of graft dysfunction, as well as sometimes identi- 
fying viral infections in these immunosuppressed patients. 



Acute rejection is histologically characterized by a 
mixed inflammatory infiltrate of the portal tracts com- 
posed primarily of T cells but with significant propor- 
tions of plasma cells, neutrophils, and eosinophils as 
well. These inflammatory cells are frequently found 
intimately associated with the epithelial cells lining the 
small interlobular bile ductules and the endothelial cells 
of the portal and centrilobular blood vessels (endothelii- 
tis). This association is believed to be due to the stronger 
expression of major histocompatibility complex anti- 
gens by the bile duct and endothelial cells when com- 
pared with the hepatocytes. As a consequence, in most 
cases of rejection the bile ductules will show evidence of 
injury or regeneration while hepatocyte necrosis is not a 
prominent feature. Biliary epithelial injury can occasion- 
ally become so severe that most of the ductules will be 
completely destroyed over a long-term course (“vanish- 
ing duct syndrome”), a condition usually requiring re- 
transplantation. Chronic injury to the liver vasculature 
has also been reported, with arteriolar thickening, fibro- 
intimal hyperplasia of the large arteries, and the accumu- 
lation of subintimal foam cells in the hilar vessels with 
partial occlusion. 

Ischemic injury to the liver is the second most com- 
mon source of acute graft dysfunction and manifests 
four basic patterns on liver biopsy — focal infarcts, mas- 
sive centrilobular necrosis, diffuse individual hepatocyte 
necrosis, and centrilobular hepatocyte ballooning. Focal 
infarcts occur as a result of ischemia of a specific portion 
of the liver either perioperatively or from postoperative 
vascular occlusion. They can vary in size and distribu- 
tion, histologically showing confluent tissue necrosis 
with adjacent viable tissue; because of the focal nature of 
this lesion, a single liver biopsy may not detect it. The 
clinical sequelae of infarction depend on its extent and 
whether the necrotic tissues becomes secondarily infected. 

Generalized, massive centrilobular necrosis is the re- 
sult of diffuse liver injury, such as severe hypotension; 
this histologic finding usually leads to retransplantation. 
Diffuse, scattered, individual hepatocyte necrosis with- 
out inflammation is also a pattern of generalized ischemic 
injury, and depending on the severity of the insult there 
may be only a few necrotic cells within the lobule or 
numerous necrotic cells followed within three days by 
generalized graft destruction. Less severe generalized 
ischemic injury results in centrilobular hepatocyte “bal- 
looning” in which liver cells around the central vein 
become notably swollen, with clear, “hydropic” cyto- 
plasm. In most cases this swelling resolves without seque- 
lae; in severe cases, however, there may be eventual 
centrilobular hepatocyte loss followed by pronounced 
cholestasis without apparent duct obstruction. 

Viral infection clinically mimicking rejection or is- 
chemia can be detected by biopsy in many cases. The 
most common virus is cytomegalovirus, but herpesvirus, 
adenovirus, and hepatitis B virus have also been de- 
scribed. Characteristic viral inclusions or patterns of 

necrotic hepatocytes in association with inflammatory 
cells are clues to viral infection. Immunohistochemical 
stains and DNA hybridization studies can also be used 
on the biopsy tissue to detect viral infection. 

Although the histologic patterns have been described 
individually, rejection, ischemia, and viral infections can 
occur simultaneously, with each contributing to a vary- 
ing degree to the extent of liver injury. 

Richard Ray, M.D. 

Klaus J. Lewin, M.D., FRCPath 
Los Angeles 


Caine R (Ed): Liver Transplantation: The Cambridge-King’s Col- 
lege Hospital Experience, 2nd Ed. Orlando, Fla, Grune & Stratton, 

Demetris AJ, Jaffe R, Starzl TE: A review of adult and pediatric 
post-transplant liver pathology. Pathol Annu 1987;22(pt 2):347-86. 

Ray RA, Lewin KJ, Colonna J, et al: The role of liver biopsy in 
evaluating acute allograft dysfunction following liver transplantation. 
Hum Pathol, in press. 

Snover DC, Freese DK, Sharp HL, et al: Liver allograft rejection: 
An analysis of the use of biopsy in determining outcome of rejection. 
Am J Surg Pathol 1987;1:1-10. 

The Molecular Pathology of 
Prion Diseases 

ing discovered for the group of central nervous 
system (CNS) diseases that includes Creutzfeldt- Jakob 
disease, the Gerstmann-Straussler syndrome, and kuru 
in humans and scrapie in animals. These disorders have 
been grouped together because they have similar clinical, 
genetic, and histologic features — spongiform degenera- 
tion of neurons, astrocytic gliosis, and amyloid plaque 
formation — and because each is infectious. Originally it 
was postulated that they were caused by an atypical virus 
because of the small size of the infectious particle pre- 
dicted from experimental studies and the absence of 
histopathologic features characteristic of viral infections. 
That possibility, however, is now considered unlikely 
because of studies at the University of California at San 
Francisco showing that highly purified preparations of 
the scrapie agent consist almost entirely of a single pro- 
tein and no detectable nucleic acid. For this reason, the 
smallest infectious particle was termed a “prion” and the 
protein associated with infectivity was termed the “prion 

Although the structure of the prion and the precise 
role of the prion protein in infectivity are not known, it 
has been learned that the prion protein is an abnormal 
derivative of a normally expressed CNS nerve cell sialo- 
glycolipoprotein. The normal isoform is synthesized 
continuously in hamster nerve cells, is highly susceptible 
to proteinase K digestion, and turns over rapidly. In 
contrast, the abnormal isoform resists proteinase K diges- 

VOLUME 53, NO. 2 


tion, turns over slowly, and accumulates in the brain 
during scrapie. Moreover, the abnormal isoform of the 
prion protein accumulates precisely in those regions of 
the gray matter where spongiform degeneration of nerve 
cell processes and reactive astrocytic gliosis are greatest. 
It also polymerizes into the filaments that form the amy- 
loid plaques characteristic of these diseases. 

Evidence indicates that a human isoform of the scra- 
pie prion protein causes Creutzfeldt- Jakob disease, the 
Gerstmann-Straussler syndrome, and kuru. Abnormal 
proteinase-resistant forms of the prion protein, which 
react specifically with anti-hamster prion protein anti- 
bodies, have been found in the brains of patients with 
Creutzfeldt-Jakob disease but not in normal brains or 
those of patients with Alzheimer’s disease. The amyloid 
plaques in the brains of patients with Creutzfeldt-Jakob 
disease and those with the Gerstmann-Straussler syn- 
drome react specifically with anti-hamster scrapie prion 
protein antibodies. Also, human chromosomes contain a 
single-copy prion protein gene that has been localized to 
chromosome 20. In addition, the amino acid sequence of 
the human prion protein is 90% homologous to the 
hamster and mouse prion protein. For these reasons, 
scrapie, Creutzfeldt-Jakob disease, the Gerstmann- 
Straussler syndrome, and kuru have been grouped under 
the term “prion disease.” 

The central pathogenic event in prion diseases appears 
to be the abnormal metabolism and accumulation of a 
normally expressed nerve cell protein. The unique fea- 
ture of prion diseases is that the abnormal prion protein 
appears to participate in transmitting the disease. The 
prion hypothesis is consistent with the failure to find a 
virus and with the absence of an inflammatory or immune 
response. It is genetically consistent because although 
most cases of Creutzfeldt-Jakob disease are sporadic, 
10% are dominantly inherited, and virtually all cases of 
the Gerstmann-Straussler syndrome are dominantly in- 
herited. Furthermore, the scrapie incubation time gene is 
genetically linked to the prion protein gene in mice. 
Therefore, except for infectivity, most of the features of 
these diseases are difficult to reconcile with the viral 

Prion research is now focused on determining the 
chemical differences between the normal and abnormal 
isoforms of the prion protein; whether the abnormal 
prion protein, either alone or with a cofactor, is the 
transmissible agent; and the molecular mechanisms by 
which prions induce disease. 

Stephen J. DeArmond, M.D., Ph.D. 

San Francisco 


DeArmond SJ, Mobley WC, DeMott DL, et al: Changes in the 
localization of brain prion proteins during scrapie infection. Neurology 

Prusiner SB: Prions and neurodegenerative diseases. N Engl J Med 

Prusiner SB, DeArmond SJ: Prions causing nervous system degen- 
eration. Lab Invest 1987;56:349-63. 

Polymerase Chain Reaction— 

A Novel Method for Analyzing Specific 
DNA Sequences 

HE ANALYSIS of DNA is becoming increasingly 
important in the study and diagnosis of hereditary, 
neoplastic, and infectious diseases. Often, however, the 
heterogeneity or small quantity of the sample available 
can limit the usefulness of conventional techniques. The 
polymerase chain reaction is a new enzymatic method 
for selectively replicating a specific nucleic acid sequence 
up to several hundred nucleotides in length within a 
complex mixture to facilitate its analysis. 

To use the polymerase chain reaction procedure, the 
DNA sequences flanking the region of interest must be 
known. Two short oligonucleotide primers complemen- 
tary to each of the two flanking regions but on opposite 
DNA strands are synthesized. These primers are added 
in vast molar excess to the sample DNA, which is then 
denatured and allowed to anneal to the primers. In the 
presence of deoxyribonucleoside triphosphates, a thermo- 
stable form of bacterial DNA polymerase uses each 
oligonucleotide as a primer to synthesize a copy of the 
adjacent DNA strand; each newly synthesized strand 
then provides a new template for synthesis from the 
opposite primer. By repeated cycles of denaturation, 
annealing, and synthesis, the region between the two 
primers is amplified exponentially. A 220,000-fold ampli- 
fication of the desired region can be achieved after 20 
such cycles; the amplified sequence can then be analyzed 
by a variety of techniques. Automated instrumentation 
capable of processing many specimens for the polymer- 
ase chain reaction has recently become available. 

The speed and sensitivity of the reaction procedure 
offer advantages for both prenatal and microbiologic 
diagnosis. The method has been applied to the prenatal 
diagnosis of sickle cell anemia and will find wider appli- 
cation as the genetic defects underlying other familial 
disorders are identified. It is also capable of detecting 
minute quantities of viral DNA in clinical specimens 
even before seroconversion occurs. The polymerase chain 
reaction has already proved usefyl in research laborato- 
ries for detecting mutations of cellular proto-oncogenes 
that are thought to play a role in human carcinogenesis; 
it may soon be used clinically to characterize these muta- 
tions in individual patients. 

Howard S. Fox, M.D., Ph.D. 

Tristram G. Parslow, M.D., Ph.D. 

San Francisco 


Embury SH, Scharf SJ, Saiki RK, et al: Rapid prenatal diagnosis of 
sickel cell anemia by a new method of DNA analysis. N Engl J Med 

Kwok S, Mack DH, Mullis KB, et al: Identification of human 
immunodeficiency virus sequences by using in vitro enzymatic amplifi- 
cation and oligomer cleavage detection. J Virol 1987;61:1690-94. 



Rodenhuis S, van de Wetering ML, Mooi WJ, et al: Mutational 
activation of the K-ras oncogene — A possible pathogenetic factor in 
adenocarcinoma of the lung. N Engl J Med 1987;317:929-35. 

Saiki RK, Gelfand DH, Stoffel S, et al: Primer-directed enzymatic 
amplification of DNA with a thermostable DNA polymerase. Science 

Fine-Needle Aspiration Biopsy in the 
Diagnosis of Lymphadenopathy in 
Persons at Risk for AIDS 

L ymphadenopathy is common finding in the 
acquired immunodeficiency syndrome (AIDS) and 
in the AIDS-related complex (ARC). Although this 
lymphadenopathy usually has a restricted differential 
diagnosis, it can be difficult to establish the precise cause 
of the nodal enlargement by history, physical examina- 
tion, radiographic studies, and laboratory tests. 

At the San Francisco General Hospital and Medical 
Center, we have found fine-needle aspiration (FNA) 
biopsy to be an accurate, well-tolerated, cost-effective, 
and useful method to initially evaluate lymphadeno- 
pathy in patients with AIDS or ARC. We have done 
more than 120 FNA biopsies of lymph nodes in such 

In our experience, about half the lymph node biopsy 
specimens in such patients show lymphoid hyperplasia. 
The other half reveal non-Hodgkin’s lymphoma, myco- 
bacterial infection. Kaposi’s sarcoma, Hodgkin’s disease, 
and various metastatic tumors. The smears showing 
lymphoid hyperplasia are characterized by a pleomor- 
phic population of lymphocytes, histiocytes, polymor- 
phonuclear leukocytes, plasma cells, and other lymphoid 
elements. The smears showing non-Hodgkin’s lymphoma 
are characterized by a monomorphic population of ab- 
normal lymphoid cells; we have further classified these 
cases as diffuse large cell, large cell immunoblastic, and 
small noncleaved lymphomas. The smears of patients 
with mycobacterial infections have consisted of histio- 
cytes with thousands of intracytoplasmic organisms. The 
smears showing Kaposi’s sarcoma have clusters of bland 
spindle cells not associated with inflammatory elements. 

Falsely abnormal results (“false-positives”) of FNA 
biopsies of lymph nodes in this group of patients did not 
occur in our series, but falsely normal (“false-negatives”) 
results can occur. Possible reasons for false-negative 
results include sampling errors in lymph nodes with focal 
disease, taking a biopsy of a benign lymph node in a 
patient with abnormal nodes elsewhere, and error in 
microscopic interpretation. Because false-negative FNA 
biopsies can occur, it is imperative that clinicians using 
this test realize that a benign result does not entirely rule 
out involvement of the lymph node by a malignant or 
infectious process. 

Kent Bottles, M.D. 
San Francisco 


Bottles K, Cohen MB, Nyberg D, et al: Fine needle aspiration 
cytology of lymphadenopathy in homosexual males. Diagn Cytopa- 
thol 1986;2:31-5. 

Bottles K, McPhaul L, Volberding P: Fine needle aspiration biopsy 
of patients with acquired immunodeficiency syndrome (AIDS): Expe- 
rience in an outpatient clinic. Ann Intern Med 1988;108:42-5. 

Bottles K, Miller TR, Cohen MB, et al: Fine needle aspiration 
biopsy: Has its time come? Am J Med 1986;81:525-31. 

Hales M, Bottles K, Miller TR, et al: Diagnosis of Kaposi’s sarcoma 
by fine needle aspiration biopsy. Am J Clin Pathol 1987;88:20-5. 

DNA Fingerprinting— Applications for 
Resolving Medical, Legal, and 
Criminal Issues 

T HERE is now a genetic test to determine individ- 
ual identity. This DNA test or “DNA fingerprint- 
ing” holds the same standard of certainty as a set of 
fingerprints. The test exploits the occurrence of tandem- 
repetitive regions of DNA — minisatellites — which are 
scattered throughout the human genome. The minisatel- 
lites are highly polymorphic or hypervariable, resulting 
from unequal exchanges that vary the number of short 
repeat units in a minisatellite. Researchers at Leicester 
University, England, isolated three human minisatellite 
DNA fragments by molecular cloning, each containing 
tandem repeats of closely related variants of a short 
consensus sequence. Using these cloned DNA fragments 
as probes to detect the homologous sequences in the 
restriction endonuclease-digested human DNA, they dis- 
covered DNA banding patterns (“fingerprints”) that are 
completely specific to each person. The estimated fre- 
quency of unrelated persons showing the same DNA 
fingerprint is extremely low — 5 x 10" 19 — and for siblings 
to share the same pattern is only 1 x 10‘ 6 . 

The possible applications of this test to various fields 
are immense. It opens up a novel approach in forensic 
science: bits of tissue, stains of blood, or other body 
fluids left at the scene of a crime may be used to identify 
their human source. The test has already been done by 
the Leicestershire police to identify a murderer in a group 
of several thousand suspects. A miniscule specimen is 
sufficient to yield a few micrograms of DNA, material 
whose stability confers an additional advantage for its 
use as a marker for identification. The state of California 
is planning a computerized data bank of DNA finger- 
printing information on convicted criminals to facilitate 
the rapid identification of repeat offenders. The test is 
also conclusive for all practical purposes in resolving 
cases of controversial parenthood or other familial rela- 
tionships. Recently, an immigration case concerning 
questionable maternity was settled by DNA fingerprint- 
ing, permitting the son’s emigration to England. Routine 
DNA fingerprinting by immigration authorities should 
accelerate the application process and avoid cases of 
arbitrary judgment by immigration officials. 

The test provides an unequivocal criterion for discrim- 

VOLUME 53, NO. 2 


inating between monozygotic and dizygotic twins of the 
same sex at birth, until now a problematic area in genetic 
studies involving human twins. Other potential medical 
applications of the test include monitoring engraftment 
of donor marrow; ascertaining the source of clinical 
specimens in cases of mix-up; and, perhaps eventually, 
with an expanded range of minisatellite probes or appro- 
priately synthesized oligonucleotide probes, examining 
genetic predispositions for diseases for which suitable 
markers are lacking. 

With dramatic success already shown, there is a grow- 
ing commercial interest in the test, and, in fact, the 
Imperial Chemical Industry has opened in the United 
Kingdom its first laboratory for DNA fingerprinting. 

Pradip Roy-Burman, Ph.D. 

Los Angeles 


Barinaga M: DNA fingerprinting database to finger criminals. 
Nature 1988;33 1:203. 

Jeffreys AJ, Wilson V, Thein SL: Individual-specific ‘fingerprints’ of 
human DNA. Nature 1985;316:76-9. 

Hill AV, Jeffreys AJ: Use of minisatellite DNA probes for determi- 
nation of twin zygosity at birth. Lancet 1985;2:1394-95. 

Lewin R: DNA fingerprints in health and disease. Science 1986; 

Newmark P: DNA fingerprinting to be used for British immigrants? 
Nature 1988;33 1:556. 

Newmark P: DNA fingerprinting at a price at ICI’s UK laboratory. 
Nature 1987;327:548. 

Lymphocyte Gene Rearrangement Studies 
in Formalin-Fixed, Paraffin-Embedded 
Pathology Specimens 

T HE use of recombinant DNA technologies to detect 
clonal rearrangements of immunoglobulin or T-cell 
receptor genes is becoming an increasingly valuable 
adjunct to more conventional methods in the diagnosis 
and assessment of B- or T-cell lymphoproliferative dis- 
orders. Until recently this technique depended on the 
availability of fresh or frozen tissue specimens, limiting 
its applicability in clinical medicine. We have therefore 
examined the feasibility of using our previously reported 
procedure for extracting DNA from formalin-fixed path- 
ology specimens for gene rearrangement studies in such 

We were able to show clonal rearrangement of heavy 
and light chain immunoglobulin genes in about 75% of 
blocks of formalin-fixed, paraffin-embedded B-cell lym- 
phoma specimens retrieved from the pathology archives 
at our institution. The success rate at recovering intact 
high-molecular-weight DNA varied substantially depend- 
ing on the hospital center from which the paraffin blocks 
were obtained. The most common reason for failing to 
recover high-molecular-weight DNA was the use of sub- 
optimally fixed tissue containing partially autolysed ar- 
eas. Overfixed material was also unsuitable because the 
amount of intact DNA recovered decreased with the 

increasing time of exposure to fixative. Tissues immersed 
in mercuric chloride-containg fixatives such as Zenker’s 
or B5 were not suitable for gene rearrangement studies. 

The best results will, therefore, be obtained with 
tissues sectioned and fixed in buffered formalin imme- 
diately after the surgical procedure and preferably for a 
period of no longer than 24 hours before being embedded 
in paraffin. Tissues fixed for as long as five days may still 
be usable, but the quantities of material recovered would 
be much smaller. Despite its limitations, this technique 
increased considerably the number of specimens amena- 
ble for gene rearrangement studies and should make this 
approach more applicable to the clinical evaluation of 
lymphoproliferative disorders. 

Louis Dubeau, M.D., Ph.D. 

Los Angeles 


Dubeau L, Chandler LA, Gralow JR, et al: Southern blot analysis of 
DNA extracted from formalin-fixed pathology specimens. Cancer Res 

Dubeau L, Weinberg K, Jones PA, et al: Studies on immunoglo- 
bulin gene rearrangement in formalin-fixed paraffin-embedded path- 
ology specimens. Am J Pathol 1988;130:588-94. 

Goelz SE, Hamilton SR, Vogelstein B: Purification of DNA from 
formaldehyde fixed and paraffin embedded human tissue. Biochem 
Biophys Res Commun 1985;130:118-26. 

Neuropathology of AIDS Dementia 

T HE AIDS Dementia Complex (ADC) was recog- 
nized two to three years ago as a syndrome of 
progressive neurologic dysfunction that occurs in a sub- 
stantial proportion of patients with the acquired immu- 
nodeficiency syndrome (AIDS). Patients with AIDS 
may have neurologic abnormalities as a result of one or 
more of several types of neuropathologic disorders, 
including opportunistic infections caused by viruses — 
such as cytomegalovirus, papovavirus, Herpes simplex 
and zoster viruses — Toxoplasma gondii, and fungi such 
as Cryptococcus neoformans, lymphoproliferative disor- 
ders including lymphoma and lymphomatoid granulo- 
matosis, and vascular or anoxic-ischemic lesions. Pe- 
ripheral neuropathy is also frequently found. Early in the 
AIDS epidemic, however, it became clear that cerebral 
dysfunction developed in some patients in the absence of 
any of these specific causal factors. Instead, postmortem 
examination of the patients’ brains revealed poorly de- 
fined inflammatory lesions including scattered micro- 
glial nodules and perivascular lymphocytes, and myelin 
loss with intense astrogliosis within white matter of the 
centrum semiovale of the cerebral hemispheres. Futher- 
more, Southern blotting methods, in situ hybridization, 
immunocytochemistry, and electron microscopy showed 
the presence of the human immunodeficiency virus (HIV) 
in the brains of many of these patients. A small but 
definite subset of patients seropositive for HIV appeared 
to have “pure” brain involvement by this disease without 
pepheral or systemic manifestations of the syndrome, ap- 
parently reflecting neurotropism of HIV in these patients. 



Though the ADC is now a recognized and reasonably 
defined clinicopathologic disorder, its nosology is by no 
means clear. Patients with the ADC often appear dement- 
ed out of proportion to the amount of structural damage 
in the nervous system, although the observed dementia 
corresponds to the subcortical type expected in patients 
with primarily white matter brain damage. Conversely, 
evidence of HIV infection of brain is seen in neurologi- 
cally normal patients. Although HIV forms with tropism 
for the nervous system have emerged, the cell type in the 
brain most commonly infected by HIV is one with mac- 
rophage or microglial markers. Infection of astrocytes 
has been recorded in a few cases, and there is little 
evidence for infection of neurons or oligodendrocytes. 
One hypothesis is that HIV-infected macrophages release 
a product or toxin that damages adjacent white matter. 

The pathologic diagnosis of ADC due to HIV infec- 
tion of brain is based on fairly subtle criteria. White 
matter injury may be inconspicuous unless large myelin- 
stained sections are carefully examined. Astrogliosis is 
best determined using an immunocytochemical proce- 
dure for glial fibrillary acidic protein. Finally, perivas- 
cular multinucleated cells — including giant cells — with 
foamy or granular cytoplasm are generally accepted as a 
marker for HIV within the nervous system. Commer- 
cially available antibodies and probes for HIV can also 
be used for immunocytochemistry or in situ hybridiza- 
tion. The diagnosis can even be made on brain biopsy, 
but this must be done with great caution because similar, 
though not identical, white matter changes without the 
presence of multinucleated cells may be seen in cases of 
progressive multifocal leukoencephalopathy or in reac- 
tive brain tissue around a lymphoma or other infectious 

Harry V. Vinters, M.D. 

Los Angeles 


Anders KH, Guerra WF, Tomiyasu U, et al: The neuropathology of 
AIDS — UCLA experience and review. Am J Pathol 1986; 124: 

Koyanagi Y, Miles S, Mitsuyasu RT, et al: Dual infection of the 
central nervous system by AIDS viruses with distinct cellular tropisms. 
Science 1987;236:819-22. 

Navia BA, Cho ES, Petito CK, et al: The AIDS dementia complex: 
II. Neuropathology. Ann Neurol 1986;19:525-35. 

Navia BA, Jordan BD, Price RW: The AIDS dementia complex: I. 
Clinical features. Ann Neurol 1986;19:517-24. 

Wiley CA, Schrier RD, Nelson JA, et al: Cellular localization of 
human immunodeficiency virus infection within the brains of acquired 
immune deficiency syndrome patients. Proc Natl Acad Sci USA 

Papillomavirus in the Lower Female 
Genital Tract 

H UMAN Papillomaviruses (HPV) are classified as 
genotypes, using molecular hybridization techni- 
ques to determine DNA composition, rather than as 
serotypes based on structural antigens; each genotype 
has less than 50% genome homology with the other 

types. At least 46 types of HPV have been identified, 12 
of which are associated with lesions of the female genital 

Morphologically, condylomas and cervical and vulvar 
intraepithelial neoplasia may show koilocytotic atypia; 
this koilocytosis is associated with the presence of HPV. 
Virus particles have been found in condylomas by elect- 
ron microscopy, and immunohistochemistry has local- 
ized HPV structural antigens to the nuclei of koilocytes. 

A number of hybridization techniques may be used to 
assess tissues for HPV. Southern blot hybridization, 
applicable to freshly obtained cells and tissues, is the 
most sensitive and specific techniques and can detect less 
than one copy of HPV genome per cell. Under high and 
low stringent assay conditions to vary the closeness of the 
nucleic acid hybrid match, HPV of known and unspeci- 
fied types can be detected. Dot blot hybridization is a 
faster but less specific method. In situ filter hybridization 
was developed for use with freshly exfoliated cells; it also 
yields more false-positives than the Southern blot tech- 
nique. In situ tissue hybridization on paraffin-embedded 
tissue permits specific HPV-infected cells to be identified 
and localized. With autographic detection using sulfur 
35 or tritium, the sensitivity and specificity are similar to 
those of Southern blotting; with a biotin label, the sensi- 
tivity decreases. 

Overall, the Southern blot technique has detected 
HPV DNA in 80% to 90% of cervical condylomas and 
intraepithelial neoplasia and in 70% to 95% of invasive 
cervical carcinomas. Differences exist among HPV gen- 
otypes in their distribution in the genital tract and in the 
severity of their associated lesions. In one study, 54% of 
cervical biopsy specimens of condyloma and intraepithe- 
lial neoplasia grade I were associated with HPV type 6 or 
11, 13% with type 16, 18, or 31, and 12% with unspecified 
types; in 21% no HPV was detectable. In contrast, 68% 
of biopsy specimens of cervical intraepithelial neoplasia 
grades II and III were positive for type 1 6, 1 8, or 3 1 , 1 2% 
for type 6 or 11, and 12% for unspecified types, with no 
HPV detectable in 8%. Other authors have reported 
comparable trends. 

Thus, HPV types 6 and 11 are generally found in 
ordinary condylomas, although they have infrequently 
been identified in squamous carcinomas, predominantly 
of verrucous pattern. Type 16, 18, 31, 33, 35, and 45 are 
considered to be of higher oncogenic potential and are 
found mainly in atypical condylomas, moderate and 
severe dysplasias, and carcinoma in situ and invasive 
carcinoma of the cervix and vulva. HPV 16 is the most 
common HPV type identified in invasive cervical squa- 
mous cell carcinoma, while type 18 shows a greater 
association with adenocarcinoma and adenosquamous 
carcinoma. Preliminary evidence suggests that a pro- 
gression from condyloma or cervical intraepithelial neo- 
plasia grade I to cervical intraepithelial neoplasia grade 
III is associated with type 16 or 18 or a mixed infection 
including one of these types. More than one HPV type 

VOLUME 53, NO. 2 


are detected in 10% to 20% of patients with carcinoma in 
situ. Various HPV genotypes, including types 16 and 18, 
have been detected in 1 1% of women with normal smears 
from cervical screening. 

There are differences in the physical state of the viral 
DNA in benign and malignant lesions. Viral DNA is 
present as extrachromosomal episomes in most preinva- 
sive lesions. Integrated HPV DNA has been noted in 
dysplasias, invasive carcinomas, their metastases, and 
cell lines derived from cervical carcinomas. 

These findings show important differences among 
HPV genotypes and strongly suggest that some types of 
HPV may play a role in carcinogenesis in the lower 
female genital tract. 

Shirley J. Huang, M.D. 

Los Angeles 


Reid R, Greenberg M, Jenson AB, et al: Sexually transmitted 
papillomaviral infections — I. The anatomic distribution and patho- 
logic grade of neoplastic lesions associated with different viral types. 
Am JObstet Gynecol 1987;156:212-22. 

Schneider A, Sawada E, Gissmann L, et al: Human papillomavi- 
ruses in women with a history of abnormal Papanicolaou smears and 
in their male partners. Obstet Gynecol 1987;69:554-62. 

Smotkin D, Berek JS, Fu YS, et al: Human papillomavirus deoxyri- 
bonucleic acid in adenocarcinoma and adenosquamous carcinoma of 
the uterine cervix. Obstet Gynecol 1986;68:241-44. 

Using the Polymerase Chain Reaction in 
Detecting Infectious Agents 

T HE diagnosis of infectious diseases is an important 
function of pathologists. Because most microorgan- 
isms are difficult or impossible to detect or because they 
speciate on histologic examination, a definitive diagnosis 
usually depends on culturing. This, however, can be an 
expensive and time-consuming process, and methods for 
culturing certain microorganisms are not available. Fur- 
thermore, fresh tissue is needed. 

In 1985 a new technique of DNA amplification, known 
as the polymerase chain reaction, was described. With 
this method, any DNA fragment of known sequence can 
be selectively amplified and subsequently determined by 
either dot or liquid hybridization. The DNA does not 
have to be purified and can even be directly obtained 
from deparaffinized, thick sections of formalin-fixed, 
paraffin-embedded material. Therefore, the presence of 
any infectious agent in tissue or body fluid can be estab- 
lished with sensitivity and specificity, provided that a 
portion of its DNA sequence is known. This method has 
been successfully applied to the identification of the 
human immunodeficiency virus in blood and the human 
papillomavirus in cervical carcinoma specimens. 

The method as described above, however, still involves 
hybridization using probes labeled with phosphorus 32; 
therefore, it is not suitable for routine clinical use. Recent- 
ly the procedure has been improved to the extent that the 

amplified DNA product can be directly shown as a 
visible band on an agarose gel after electrophoresis and 
staining with ethidium bromide. We have successfully 
used this protocol to identify hepatitis B virus in serum 
specimens and herpes-virus in paraffin blocks of speci- 
mens of infected skin, with 100% sensitivity and specific- 
ity. With this modifed technique, the entire procedure 
can be done in less than six hours, with no need for 
radioisotopes. Therefore, the polymerase chain reaction 
offers a rapid, sensitive, and specific technique for detect- 
ing infectious agents that can use both fresh and fixed 
material and in the future may be increasingly used in 
clinical laboratores for diagnostic purposes. 

T.S. Benedict Yen, M.D., Ph.D. 

San Francisco 


Cao M, Xiao X, Egbert B, et al: Rapid detection of herpes simplex 
virus infection with the polymerase chain reaction. J Invest Dermatol , 
in press. 

Kwok S, Mack DH, Mullis KB, et al: Identification of human 
immunodeficiency virus sequences by using in vitro enzyme amplifica- 
tion and oligomer cleavage detection. J Virol 1987;61:1690-94. 

Shibata DK, Arnheim N, Martin WJ: Detection of human papillo- 
mavirus in paraffin-embedded tissue using the polymerase chain reac- 
tion. J Exp Med 1988;167:225-30. 

Diagnosis of Small Round Cell 
Tumors in Children 

T HE term “small, round, blue cell tumors” refers 
collectively to a group of several aggressive malig- 
nant disorders of childhood of diverse histogenesis that 
are capable of presenting histologically as proliferations 
of small primitive cells with round nuclei and undifferen- 
tiated cytoplasm. The most important of these are lym- 
phoma, Ewing’s sarcoma, rhabdomyosarcoma, and neu- 
roblastoma, although a number of other disorders are 
occasionally considered in the differential. While most 
cases of each of these neoplasms can be diagnosed by 
conventional histopathology, some of these tumors elude 
identification by routine light microscopy alone. Fortu- 
nately, several ancillary techniques, including sophisti- 
cated applications of recent advantages in immunology, 
genetics, and molecular biology, are available for resolv- 
ing problematic cases. 

Electron microscopy will often provide an answer in 
these cases by revealing neuritic processes in neuroblas- 
toma, actin-myosin bundles in rhabdomyosarcoma, gly- 
cogen pools and a general lack of cytoplasmic differenti- 
ation in Ewing’s sarcoma, an absence of true cell attach- 
ments in lymphoma, and various other features. Immuno- 
cytochemistry has proved its value in the diagnosis of 
small, round, blue cell tumors. The detection of myo- 
globin or desmin or both in primitive tumor cells may 
confirm the diagnosis of rhabdomyosarcoma, while a 
positive reaction for neuron-specific enolase may point 
towards neuroblastoma or other primitive neural tumors. 



Newer monoclonal antibodies against muscle-specific 
actin and various neural antigens such as Leu-7 and 
HSAN 1.2 are providing additional help. The demon- 
stration of leukocyte-common antigen may be invalu- 
able in the diagnosis of lymphoma in an unusual site, 
while a battery of more specific markers may aid in its 
precise classification. 

The most exciting recent advances in the diagnosis of 
small, round, blue cell tumors have been in the study of 
tumor cell chromosomes and DNA by cytogenetic and 
molecular genetic methods. Specific chromosomal abnor- 
malities have been found in certain tumors, such as 
reciprocal 1 1 :22 translocation in Ewing’s sarcoma. The 
finding of the same translocation in peripheral neuro- 
epithelioma raises fascinating histogenetic possibilities. 
Studies of oncogene amplification and expression in 
small, round, blue cell tumors, such as the N -myc onco- 

gene in neuroblastoma, have been shown to provide 
useful diagnostic and prognostic information and to 
shed light on tumorigenesis. These and other newer 
developments bring us closer to our goal of a precise 
diagnosis in every case of small, round, blue cell tumor. 

Douglas A. Weeks, M.D. 

Loma Linda, California 


Brodeur GM, Seeger RC, Schwab M, et al: Amplifications of N-myc 
in untreated human neuroblastomas correlates with advanced disease 
stage. Science 1984;224:1121-24. 

Mierau GW, Berry PJ, Orsini EN: Small round cell neoplasms: Can 
electron microscopy and immunohistochemical studies accurately class- 
ify them? Ultrastruct Pathol 1985;9:99-111. 

Triche TJ, Askin FB, Kissane JM: Neuroblastoma, Ewing’s sar- 
coma, and the differential diagnosis of small-, round-, blue-cell tumors, 
In Finegold M (Ed): Pathology of Neoplasia in Children and Adoles- 
cents. Philadelphia, WB Saunders, 1986, pp 145-95. 


Norris B. Finlayson, M.D. 

CM A Section Chair 
Mountain View 

Joan A. Howanitz, M.D. 

CM A Section Secretary 
West Los Angeles 

R. Eugene Tolls, M.D. 

CM A Section Assistant Secretary 
San Francisco 

Brian S. Bull, M.D. 

Loma Linda University 

George Kypridakis, M.D. 
Advisory Panel Chair 
Section Editor 

CM A Scientific Board Representative 
Los Angeles 

Klaus G. Bensch, M.D. 

Stanford University 

Murray Gardner, M.D. 

University of California, Davis 

Yutaka Kikkawa, M.D. 

University of California, Irvine 

Pasquale A. Cancilla, M.D. 

University of California, Los Angeles 

Colin M. Bloor, M.D. 

University of California, San Diego 

Dorothy F. Bainton, M.D. 

University of California, San Francisco 

Clive R. Taylor, M.D., Ph.D. 
University of Southern California 

Richard P. Henke, M.D. 

Long Beach 

James L. Bennington, M.D. 

San Francisco 

Stephen N. Bauer, M.D. 

Stephen C. Hansen, M.D. 


VOLUME 53, NO. 2 


a Part of Your Life 

You don’t have time to waste on medical writing that is cluttered 
with complicated statistics and data. Depend on Postgraduate Medicine 
to provide you with clearly written, well-illustrated articles on matters 
i of practical importance in your daily life. 

The World’s Longest Insulin Patient 


W HEN Dr. Morton Ryder, a 1918 graduate of 
Cornell University Medical College, journeyed to 
Toronto early in June 1922 to see Dr. Frederick Banting, 
the survival of his young diabetic nephew was much in 
doubt. Weighing 26 pounds, five-year-old Teddy Ryder 
had been kept alive for almost two years through a 
near-starvation diet, the only life-prolonging treatment 
for diabetes then known. Teddy had seemed so close to 
death the previous December that his family had not 
bought a Christmas tree, fearing the boy would not last 
until Christmas Day. Somehow he did survive, though, 
and in February 1922 a newspaper report from Toronto 
broke the electrifying news of the experiments of Banting 
and Charles Best with insulin. Dr. Ryder quickly wrote 
to Banting, but then, unaccountably, the knack of making 
the pancreatic extract was lost, not to be regained until 
the end of May. A little over a week later Dr. Ryder set 
out for Toronto to plead his nephew’s case directly to Dr. 

Today, thanks to his uncle’s intervention, Ted Ryder 
lives comfortably in his West Hartford, Connecticut, 
apartment, having taken insulin longer than anyone else 
in the world. He is 71 years old. 

Teddy had been a normal, healthy child until he was 
four. “At that time,” his late mother, Mildred, recalled in 
an interview with The Toronto Star in 1983, “he was 
growing tall, but he wasn’t putting on any weight. And he 
couldn’t get enough to eat.” It was the Ryders’ family 
physician in Keyport, New Jersey, who diagnosed dia- 
betes. Dr. Ryder, then interning at Bellevue, hurried out 
that night to the family, but the news he had for his 
brother and sister-in-law was no comfort: within a short 
time, he told them, their young son would probably be 

The Ryders refused to give up hope for Teddy, slim 
though his chances for survival might be. Looking to 
prolong his life by any means possible, they took him to a 

LEROY H. WARDNER, M.D., practiced obstetrics and gynecol- 
ogy as a staff member of Hartford Hospital and has been retired since 

Reprinted with permission from Cornell University Medical College 
Alumni Quarterly, Vol. 49, No. 4, April 1988. 

physiatric institute in Morristown, New Jersey, run by 
Dr. Frederick Allen, an eminent diabetologist known for 
his brusque manner and extremely restrictive diets. After 
his first meal at the institute, the four-year-old patient 
commented, “Mama, they don’t know how to feed little 
boys here.” Years later he would recall, “They’d give you 
cabbage; they’d cook this stuff three times, they’d throw 
out the juice and with it most of the flavor. So you had 
this sort of colorless, tasteless roughage, and I guess you 
thought you’d eaten after you finished it.” Existing on a 
diet of jellies and washed bran cookies in addition to the 
thrice-cooked cabbage, Teddy began a scrapbook in 
which he put pictures of food he had cut out of mag- 

On his visit to Toronto early in June, Morton Ryder 
was told by Banting to bring Teddy for treatment in 
September. The young physician replied that his nephew 
would not be alive by then. Returning to New York with 
the hope that treatment could be arranged earlier, Dr. 
Ryder wrote a long letter to Banting on June 25 seeking a 
commitment for early treatment and laying out in detail 
his nephew’s medical history. Because the letter so well 
illustrates what an all-but-impossible struggle the treat- 
ment of diabetes once was, I will quote it virtually in its 

In accordance with our conversation of June 
1st, in Toronto, I am writing to learn whether, as 
you then anticipated, you will be able to treat my 
little nephew by about July 1st. 

The family would be unable to continue treat- 
ment indefinitely, should the expense of prepara- 
tion of the extract continue to be as high as the 
figure you then mentioned, but, if it is likely to be 
more reasonable within a few months, they will 
gladly pay whatever is necessary at the present 
time. It seems to be pretty clear that we must not 
delay if the boy’s life is to be saved. (Perhaps you 
have a better idea now of what the expense is likely 
to be by the end of the summer.) 

If you are able to take him, the mother will come 
with him and stay in Toronto as long as you 
consider it necessary for him to be there. You 

VOLUME 53, NO. 2 


mentioned something like two months. 

I am sending an outline of the case that you may 
have a better idea of it. As I told you, his diabetes 
has been rigidly controlled, to the extent not merely 
of keeping the urine sugar-free and practically 
acetone-free, but to the extent of keeping the blood 
sugar constantly normal, regardless of weight, 
strength, and so on. This has been done in the firm 
belief that it is the means of prolonging life as far as 
possible, and this we have wanted to do, in the 
hope of just such a cure as you have developed. He 
has now lived a year and eight months since 
diabetes was discovered, at the age of four. He has 
been under the care of Dr. F. M. Allen (for the first 
year) and Dr. H. O. Mosenthal, and quite tho- 
roughly studied, so that a cure, in your hands, will 
mean a good deal. 

Briefly, the history is as follows. (In the event of 
your accepting him, we can send you his record in 
detail, day by day, with a complete account of his 
diet, and all his laboratory findings.) 

Theodore Ryder, 5 years, 9 months. 

Family history: Both parents well. No diabetes. 
One sister (2 years) well. Grandparents: no diabetes 
— three living and well. Great-grandparents: two 
had diabetes in old age. 

Personal history: Normal birth. Breast-fed. No 
exanthems. Weight normal till 3 years old — no 
gain after that. No serious illnesses, no serious 
accidents. Nocturnal enuresis began suddenly Sep- 
tember 1920. 

Diabetic history: Discovered by family physician, 
November 1, 1920 (age 4 years, 2 months). At this 
time had polyuria, polydipsia and polyphagia (the 
last slight and of about two weeks duration). Dry 
skin and lips, slightly flushed cheeks. Mentality 

November 1-19, 1920: Regular diet. Treated by 
family physician by oxygen inhalations and rectal 
injections of oxygen; 24-hour specimens of urine 
on the 17th and 18th contained 90 and 120 grams 
of glucose, about two thirds of the weight of carbo- 
hydrate ingested in the food. 

November 19-December 3, 1920: Treated at Dr. 
F. M. Allen’s sanatorium at Morristown, New 
Jersey. Put on a diet of protein/ 30, carbohy- 
drate/ 10. Became sugar-free and had a normal 
blood within 24 hours. Diet gradually increased, 
controlled by frequent blood-sugar determinations. 
Discharged with normal blood sugar on diet of 
protein/45, fat/ 62, carbo/15 — 800 calories. The 
diet was accurately weighed out at home and 
regulated by blood-sugar determinations every two 
weeks at Morristown. 

March 1, 1921: Apparently in equilibrium on 
protein/ 50, fat/ 66, carbo/20 — 900 calories. In- 

crease to 1,000 calories regularly caused hyper- 

May 10-22, 1921: At Dr. Allen’s again for re- 
determination of tolerance (Dr. A. believed patient 
had broken diet). Discharged with normal blood 
sugar on protein/40, fat/64, carbo/15 — 800 cal- 

July 31, 1921: Has hyperglycemia on protein/ 35, 
fat/ 58, carbo/ 10 — 700 calories. 

September 12, 1921: Hyperglycemia (155) on 
protein/ 25, fat/ 31, carbo/ 5 — 400 calories. 

September 13, 1921: Put under care of Dr. H. O. 
Mosenthal, of New York. The change was made 
because we wished to allow an increase of diet that 
would cause hyperglycemia, though not glyco- 
suria — and Dr. Allen could not be persuaded to 
adopt such a compromise. 

September 13: Protein/30, fat/60, carbo/ 10 — 
700 calories. 

October 12, 1921: Has had no glycosuria. Blood 
sugar determinations were not made. Diet increased 
to protein/34, fat/64, carbo/ 10 — 750 calories. 

October 17, 1921: Glycosuria (first since treat- 
ment began, November 19, 1920). 

October 17-December 10, 1921. Diet varied from 
400 to 750 calories, exclusive of fast days. Various 
combinationes were tried .... There was frequent 
glycosuria and acetonuria; blood-sugar determina- 
tions not made. The patient did not feel at all well 
during this period. 

December 10, 1921: Went back to strict ‘Allen 
regime,’ under care of Dr. M. Ryder. The diet has 
been gradually increased from protein/ 20, fat/ 15, 
carbo/ 0, calories 224 to protein/ 20, fat/ 36, carbo/ 5, 
calories 425. The blood sugar fell to normal, and 
has remained so. There has been no ketonuria and 
no glycosuria except for one day on each of two 
occasions, when the diet was raised somewhat 
above the last figures. 

During the period from December 10- June 24, 
under strict control of the diabetes, patient lost 
about four pounds (from 30 to 26). He has, how- 
ever, felt invariably well and has been about the 
house continually, with no illness save for occa- 
sional transient constipation. This has been met by 
frequent colon irrigations. Agar-agar jellies, washed 
bran cookies, broth, and thrice-boiled vegetables 
have been used rather extensively to appease hun- 
ger, though they have been curtailed as much as 
possible to avoid too great distension of the ab- 

The urine contained a trace of acetone (nitro- 
prusside reaction) constantly for the first year of 
treatment, but during the last six months there has 
been none, although the fat/glucose ratio has for 
some time been 2.1. 



Dr. Morton Ryder (top left) in 1922, the year he wrote Banting on behalf of his nephew, and Dr. Maurice Root (top right) as a medical student. 
Below, classmates Ryder and Root (front row left and right respectively) as members of a student club at Cornell University Medical College in 1 9 1 5. 

VOLUME 53, NO. 2 


For a time, sodium hydrogen carbonate was 
given in small doses, not to combat the trivial 
acidosis but to allow water retention and so pre- 
vent too great loss of weight. Recently no soda has 
been used, but the patient is allowed generous 
rations of table salt, with the same end in view. 

He is now, as you will judge from the weight (26 
pounds), very considerably emaciated. He walks 
about the house, though to look at his legs one 
would suppose him unable even to stand. He can 
be interested in numerous diversions, but for 
months has not had the energy to play by himself. 

Occasionally he is very irritable, and rarely al- 
most unmanageable. It looks to me as though a 
very few more months on this starvation diet will 
be all he can hold out — and we are very sure that 
any increase of diet would shorten his existence. 

I need not tell you how earnestly I hope that you 
will see your way clear to treat him. We will try to 
pay whatever fee you consider due yourself: it 
would be very unfair for you to charge only the 
expense of preparation of the extract, as you spoke 
of doing. 

Hoping for an early consideration of the case, I 
am, yours sincerely, Morton Ryder. 

The Ryders had their answer in a letter dated June 28: 

Your letter of June 25th is received. I have made 
plans to commence treatment of your nephew 
about the first of July or any time after that date. 
Extract is still difficult to obtain, but we are doing 
our best. Yours sincerely, F. G. Banting. 

Teddy and Mildred Ryder arrived in Toronto by train 
on July 8. Being too weak to walk, Teddy had to be 
carried almost everywhere by his mother. For the first 
two days in Toronto, no insulin was available, the 
remainder of the last batch having gone bad. But on 
Monday, July 10, 1922, Teddy Ryder received his first 
insulin injection and stopped dying. Years later Ted 
expressed regret at not being able to remember who gave 
him his first shot, but it was Banting himself who usually 
came to the room that the Ryders had rented, bringing 
the precious vials of insulin and giving Teddy his injec- 
tions. “Sometimes he had to have three or four injections 
a day,” Mildred Ryder recalled in 1983. “Dr. Banting 
would say, ‘Well, we tried this on a rabbit, and we’d 
better go easy on this lot — it may be too strong.’ But if 
there was any little sign of Teddy’s having a reaction, he 
would come running.” 

Banting, she added, would sometimes drop by in the 
evening to talk. “He would tell about his troubles with a 
particular young lady. He’d asked her a dozen times to 
marry him in the past and he’d always been refused. Now 
she wanted to come back, and he didn’t know what to 

Banting, she said, would also expound at length about 
Professor J. J. R. Macleod, who had reluctantly given 


Ted Ryder, now 71 years old. A patient of Dr. Maurice Root for over 
50 years, he is now in the care of Dr. David Wilcox ’55. 

Banting laboratory space, but who now seemed deter- 
mined to take credit for the discovery. 

Banting was like a favorite uncle to the small group of 
patients he agreed to treat that summer, taking them for 
rides in the country in his new car or dressing up in 
costume for one of their birthday parties. On one occa- 
sion he took Teddy and his mother on a tour of the 
laboratory at the University of Toronto where he and 
Best had slept alongside the dogs they used in their 
experiments and where they would cook their food over 
bunsen burners while the experiments progressed. 

Years later Mrs. Ryder could recall no single moment 
when she realized Teddy was going to live, but he was 
filling out steadily. By the time the Ryders returned to 
New Jersey in early October, the change in the little boy 
was dramatic. Morton Ryder, who had not seen Teddy 
in months, wrote to Banting, “I cannot tell you too 
strongly how much I am pleased with what you have 
accomplished.” Teddy wrote to his hero in Toronto as 

Dear Dr. Banting, I wish you could come and 
see me. I am a fat boy now and I feel fine. I can 
climb a tree. Margaret (Teddy’s sister) would like 
to see you. Lots of love from Teddy Ryder. 

When Banting addressed a packed hall of physicians 
in New Jersey the following January, he had Teddy, now 
a chubby little boy, come up and sit on his knee. 

In 1929, the Ryders revisited Toronto, where Teddy’s 
grandfather, who had paid much of the cost of his treat- 
ment, attended a bankers’ conference. On that occasion 
the Ryders took what was probably the earliest movie of 
Banting working in his laboratory. 

Ted Ryder’s life since insulin has had a reassuringly 
normal course. In 1925 his family moved to Hartford, 


Connecticut, where his father, an engineer, became one 
of the first employees of Pratt & Whitney, the manufac- 
turer of aircraft engines. Ted attended Trinity College in 
Hartford before receiving a degree in History from Cor- 
nell, the alma mater of three generations of the Ryder 
family. It was the first time he had been far from the 
protective care of his mother. 

Since Ted’s graduation from Cornell in 1942, he has 
had a varied career. He has worked as a librarian, carto- 
grapher, and bookseller, traveling to areas as remote as 
James Bay, Canada. To his regret, he has been a life-long 
bachelor. “It’s lonesome,” he lamented in a 1983 inter- 
view. “It’s frustrating not to have a companion and to be 

Ted Ryder’s good health and longevity are particu- 
larly notable because of the lack of consistency in the 
quality and potency of early insulin injections. Undoubt- 
edly much of the credit for his continued health must go 
to another Cornell graduate and friend of his uncle’s, 
Maurice (Tim) Root T8, who was Ted’s physician for 
over 50 years. Dr. Root, an alert 96, now lives in Rock- 
land, Maine. 

Ted has been cared for by David S. Wilcox, CUMC 
’55, since 1981, during which time he has had four 
hospitalizations. Initially he was admitted to change his 
insulin program to regular and protamine zinc, and he 

was later changed to NPH alone. His only manifest 
complication was neuropathy. 

On three occasions he has required amputation of a 
single toe as a result of gangrene and localized infection 
in association with his neuropathy. At each admission he 
has had a normal ECG, normal BUN and creatinine, and 
no other complications of his 67 years of diabetes. He has 
retained good vision and good cardiac and renal func- 
tion and continues active and independent. 

Morton Ryder practiced internal medicine with dis- 
tinction for many years in Rye, New York, serving for 24 
years as chief of the medical staff at United Hospital in 
Port Chester. Dr. Ryder retired in 1966, and died in 1980 
at the age of 85. 

Mildred Ryder lived to the age of 93. She was my 
patient, and right to the end retained the vigor, strong 
will, and solicitude for her son that had saved his life 
decades earlier. “We were lucky,” she told a reporter not 
long before she died. “We had Uncle Morton to back us 
up. I look on it as Dr. Banting’s miracle. We have lived 
through remarkable times.” 

This article was made possible by the keen interest and cooperation 
of members of the Ryder family and of Michael Bliss, professor of 
history at the University of Toronto, who furnished excerpts, photo- 
graphs, and information from the Sir Frederick Banting Archives. 
Professor Bliss’ Banting, a Biography was published in Canada in 1984. 


MAY 10, 11, 1989 



VOLUME 53, NO. 2 




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The Future of Family Practice 

Implications of the Changing Environment of Medicine 


T HE Council on Long Range Planning and Devel- 
opment of the American Medical Association 
(AMA) has been studying trends in the environment of 
medicine and assessing the impact of these trends on 
health care delivery. 1 The Council realizes that each 
medical specialty has unique characteristics and will 
respond differently to the anticipated changes in the 
environment of medicine. This report, part of a continu- 
ing series prepared by the Council, focuses on the spe- 
cialty of family practice. 


Family practice is characterized by an orientation 
away from increased segmentation of patient care and 
toward a model in which the physician provides a wide 
assortment of medical care for the patient from the 
prenatal period to death. This specialty had its roots in 
general practice, and a number of factors contributed to 
its inception. 

In 1940, three of every four physicians in patient care 
were general practitioners. With WW II the age of spe- 
cialization began to flourish, which brought a rapidly 
changing medical environment. By 1949, general practi- 
tioners represented two out of three physicians in patient 
care, but their practices were changing. While they were 
striving for hospital privileges on the basis of proved 
capability, specialty-oriented hospital medical staffs were 
establishing requirements that frequently included board 
certification. Tn^addition to restriction of hospital privi- 
leges, general practice residency training was extremely 
limited. As the board-certified specialists gained stature, 

From the Council on Long Range Planning and Development, 
American Medical Association, Chicago, in cooperation with the 
American Academy of Family Physicians, Kansas City, Mo. 

Members of the Council on Long Range Planning and Development 
include the following: Frank B. Walker II, MD, Chairman; Palma E. 
Formica, MD, Vice Chairman; Kim A. Bateman, MD; Alan C. Hart- 
ford; Richard F. Labasky, MD; Jonathan E. Rhoads, JR, MD; C. 
Burns Roehrig, MD; Alex Scott, MD; John K. Scott, MD; Robert S. 
Stone, MD; Thomas M. Gorey, JD, Council Secretary; and Holly J. 
Mulvey, AMA Department of Long Range Policy Analysis, Consult- 
ing Author. 

the status of the general practitioner diminished. These 
challenges prompted a series of actions by general practi- 
tioners not only to survive but to strengthen and improve 
their position in American medicine. 2 

Their initial steps were to provide a basis and united 
voice for their concerns and objectives. The year 1946 
marked the first meeting of the Section on General Prac- 
tice of the AMA, and 1947 saw the formation of an 
organization to specifically represent general practition- 
ers, the American Academy of General Practice (AAGP). 
In 1957, the AMA established a joint committee, with 
representatives from its Council on Medical Education 
and Section on General Practice as well as the Associa- 
tion of American Medical Colleges (AAMC) and the 
AAGP, to “objectively analyze and make recommenda- 
tions as to the best background preparation today for 
general practice.” 2 The final report of the Committee on 
Preparation for General Practice of the AMA (adopted 
by the AMA House of Delegates in 1959) stressed the 
physician’s interaction with the patient and family, estab- 
lished the terms family practice and family physician, 
and proposed the development of new graduate educa- 
tion programs for family practice. 3 

In addition to these actions by the medical profession, 
the public and government agencies became involved. 
Four special commissions working independently and 
with varying agendas issued reports calling for increasing 
the number of family physicians and changes in medical 
education. One of these, the Report of the Ad Hoc 
Committee on Education for Family Practice, “Meeting 
the Challenge of Family Practice” (adopted by the AMA 
in 1966), greatly contributed to subsequent efforts to 
develop essentials for family practice residency programs 
and to obtain approval for a certifying board. 4 

This report was prepared by representatives from the 
Council on Medical Education and the Section on Gen- 
eral Practice of the AMA, the AAMC, and the AAGP 
(changed in 1971 to the American Academy of Family 
Physicians [AAFP]). Its several recommendations in- 

VOLUME 53, NO. 2 


eluded the following: that the recognition and status 
accorded to family practice should equal that of other 
medical specialties, that incentives should be developed 
for medical students and young physicians to enter this 
specialty, and that funds should be allocated to support 
family practice teaching programs and research in patient 
care and community medicine. 4 These issues, which con- 
tinue to be of interest and concern to the specialty of 
family practice, are addressed later herein. 

Table 1 

Data for Federal and Nonfederal Physicians* 

All Physicians, No. (%) 

Foreign Medical 






334,028 (100) 

25,401 (7.7) 




35,636 (9.1) 

80,848 (20.5) 



54,284 (11.6) 

97,726 (20.9) 


519,546 (100) 

69,588 (13.4) 

112,005 (21.6) 


569,160 (100) 

86,670 (15.2) 

123,090 (21.6) 


Practice Physicians, 

No. (%) 


57,948 (100) 

2,486 (4.3) 



54,557 (100) 

2,866 (5.2) 

7,757 (14.2) 



4,677 (7.8) 




6,706 (10.4) 



67,687 (100) 

8,724 (12.9) 

12,589 (18.6) 

*From Roback and colleagues: Physician Characteristics and Dis- 
tribution in the U.S. 5 

In 1969, the American Board of Family Practice 
(ABFP) was established as the 20th primary certifying 
board in American medicine. Two elements in this certi- 
fying board’s requirements were unique: (1) a “practice- 
eligible” route to sit for the certification examination and 
(2) a provision for mandatory recertification every six 
years to maintain ABFP diplomate status. 

Explicit identification of the specialty of family prac- 
tice and the physicians practicing this specialty was then 
reviewed and refined. The following definition of family 
physicians was officially endorsed by the AAFP Con- 
gress of Delegates in 1975: 

The family physician provides health care in the discipline of family 
practice. His / her training and experience qualify him / her to practice in 
the several fields of medicine and surgery. The family physician is 
educated and trained to develop and bring to bear in practice unique 
attitudes and skills which qualify him or her to provide continuing, 
comprehensive health maintenance and medical care to the entire 
family regardless of sex, age or type of problem, be it biological, 
behavioral or social. This physician serves as the patient’s or family’s 
advocate in all health-related matters, including the appropriate use of 
consultants and community resources. 

Current Socioeconomic Indicators 
Relevant to Family Practice 

To provide a context for the issues affecting the spe- 
cialty, this section will review the demographic trends 
and socioeconomic indicators of family practice. Data 
from the AMA Physician Masterfile 5 reveal that over a 
21 -year period (1965-1986) the number of US family 
physicians (including general practitioners) in both fed- 
eral and nonfederal practice declined to a low in 1975 
and gradually increased through 1986 (Table 1). From a 
total family physician count of 54,557 in 1975, the 


number of physicians in this specialty increased by 24% 
to 67,687 in 1986. In 1975, family physicians accounted 
for 13.8% of the total physician population of 393,742. 
Given the greater increase in the total physician popula- 
tion, in 1986 family physicians represented 1 1.9% of the 
physician total of 569,160. In terms of size, family prac- 
tice is ranked second among all specialties (Fig l). 5 

Figure 1 

Trends in distribution of federal and nonfederal physicians by specialty 
for selected years. Open circles indicate general practice and family 
practice; closed triangles, internal medicine; squares, general surgery, 
closed circles, psychiatry; and open triangles, pediatrics (from Roback 
and colleagues: Physician Characteristics and Distribution in the US 5 ). 

According to the National Ambulatory Medical Care 
Survey, 6 30.5% of the 636,386,000 patient visits to office- 
based physicians in 1985 were to family physicians. In 
comparison, internists were the next highest, with 11.6% 
of patient visits, and 11.4% were to pediatricians, the 
other major providers of primary care (Table 2). 6 

Table 2 

Distribution of Office Visits by Specialty, Type of Practice, 
and Professional Identity in 1985* 

Physician Specialty, Type of Practice, 

No. (%) of Visits 

and Professional Identity 

in Thousands 


Family practice 



Internal medicine 






Obstetrics and gynecology 






Orthopedic surgery 



General surgery 












Urologic surgery 



Cardiovascular disease 






All other specialties 



Type of Practice 










Professional identity 







Total visits 

636^86 (100.0) 

*From the National Ambulatory Medical Care Survey, cited by 
American Academy of Family Physicians: Facts About Family 
Practice . 6 

t Includes group practice. 

In 1986, foreign medical graduates (FMGs) repre- 
sented 18.6% of the total family physician population. 


and women represented 12.9%. This compares with 
I 21.6% FMGs and 15.2% women in the total physician 
population. Although FMGs and women constitute a 
smaller percentage of family physicians than physicians 
overall, family practice is second among all specialties in 
respect to the number of FMGs in the specialty and third 
as to the number of women. 5 

( Compared with all physicians, family physicians in 
1986 spent slightly more time in practice during the year 

I (mean, 48.3 weeks per year for family physicians vs 47.5 
weeks per year for all physicians). According to AMA 
data, family physicians devoted 57.9 mean hours per 

I week to professional activities, of which 48.9 were in 
direct patient care. This practice pattern is virtually iden- 
tical to that of physicians overall. 7 

Family physicians conduct more patient visits per 
week than physicians overall. However, patient visits for 
family physicians declined approximately 15% between 
1976 and 1986, from an average of 163.6 per week to 
139.2 per week. This mirrors the decline in weekly patient 
visits for physicians overall, from an average of 134.7 in 
1976 to 1 17.7 in 1986. Patients of family physicians wait 
approximately 2.7 days to be scheduled for an appoint- 
ment; for physicians overall, patients on average wait 6.2 
days to be scheduled for an appointment. 7 

The mean fee for family physicians in 1986 for an 
office visit with an established patient was $23.48. For 
physicians overall, the mean fees were higher on average, 
at $30.10. In 1986, for physicians in the specialty of 
family practice, the mean net income after expenses and 
before taxes was $80,300. For all physicians the mean net 
income was $119,500 (Figure 2). 7 

Figure 2 

Mean net income of physicians after expenses and before taxes (from 
Gonzalez and Emmons [eds]: Socioeconomic Characteristics of Medi- 
cal Practice, 1987 1 ). 

The most common practice arrangements for family 
physicians are solo practice and family practice groups. 
Approximately 44% of all office-based family physicians 
who provide direct patient care are in solo practice, and 
roughly 27% are in family practice groups. The remain- 
der are almost evenly divided between two-person part- 
nerships and multispecialty groups (Table 3). 9 

Table 3 

Practice Profile of Family Physicians in May 1987* 

Practice Category 



Professional activity 
(majority of time) (n = 31,300) 



Direct patient care 






Not reported 


Direct patient care (n = 29,256) 

Alternative modes of health care delivery 



Health maintenance organization 


Independent practice association 


Preferred provider organization 


Free-standing emergency center 


Hospital satellite clinic 




Not reported 


Practice base 





Other (school, industrial, etc) 


Not reported 


Office-based direct patient care (n = 26,644) 

Practice arrangement 



Two-person partnership 


Family practice group 


Multispecialty group 


Not reported 


Type of income 

Fee for service 


Salary plus percentage 


Straight salary 


Not reported 


*From American Academy of Family Physicians: Facts About 
Family Practice . 9 

t Percentages do not add to 100% because some physicians are in 
more than one category. 

Forces for Change 

The Council on Long Range Planning and Develop- 
ment of the AMA, in consultation with the AAFP, has 
identified several key issues that have implications for the 
future of the specialty of family practice. These issues 
relate to professional and public image, graduate medi- 
cal education, reimbursement, scope of practice, man- 
aged care, professional liability, manpower, and ethics. 
Professional and Public Image 

After family practice was formally established as a 
board-certified specialty it continued to experience some 
negative sentiments from within the medical profession. 
With the many advances that have been made in the 
intervening years, family practice by and large has 
achieved the status and influence of other medical spe- 
cialties. There are occasional exceptions, however, par- 
ticularly in academic centers. 

The fact that family physicians provide comprehen- 
sive patient care from the prenatal period to death often 
puts them in direct competition in one way or another 
with many other specialties. Family physicians have 
always maintained that they refer patients to other medi- 
cal specialists as appropriate. However, the perception of 

VOLUME 53, NO. 2 


some physicians in other specialties is that even the initial 
services provided by family physicians represent an in- 
fringement on their scope of practice. Presently, the 
greatest overlap and, therefore, the most opportunity for 
competition, comes from within the primary-care spe- 
cialties of internal medicine, pediatrics, and obstetrics 
and gynecology. 

A factor that might have initially contributed to the 
ambiguous status of family physicians is that their in- 
tended expertise lies in a “generalist” practice of medicine 
and that family practice was termed a specialty in breadth 
rather than depth. The development and growth of spe- 
cialties from their inception through the 1960s were 
based on in-depth expertise in a defined body system (eg, 
urology), the age or gender of the patient (eg, obstetrics 
and gynecology), or specific types of technology (eg, 
nuclear medicine). The fact that family practice by its 
very definition does not adhere to this traditional pattern 
— a clearly delineated role in a specific area of expertise — 
gives family physicians a lesser level of influence among 
their medical colleagues. 8 Before the establishment of 
accredited family practice residencies and the certifying 
board (ABFP), family physicians were viewed as having 
less training than their colleagues in other specialties. 
This perception has been largely dispelled, and family 
practice has taken the lead by being the first specialty 
board to require periodic recertification. 

The lack of emphasis on a research and publication 
orientation for this specialty is another factor contribut- 
ing to a perceived lower status within the profession. 
According to a 1987 A AFP Practice Profile Survey, 9 
0.2% of the respondents identified “research” as their 
main professional activity, and 3.3% stated that “teach- 
ing” was their primary professional activity. In compari- 
son, 93.5% of the physicians in this specialty listed their 
professional activity as “direct patient care” (Table 3). 

A recent survey of graduates of the several Robert 
Wood Johnson Foundation Family Practice Academic 
Fellowship Programs shows that the research environ- 
ment in departments of family practice is often far from 
optimal. This study concluded that only a minority of the 
research-trained faculty had significant time budgeted 
for research. 10 It must be noted, however, that because 
family practice is a relatively new specialty, a limited 
number of physicians have graduated from family prac- 
tice residency programs and pursued an academic career 
to, in turn, direct graduate medical education in this 
specialty. Obtaining funding for research has been and 
continues to be an obstacle for family practice physi- 
cians. However, a more positive environment is develop- 
ing, marked by a trend toward research conducted in 
ambulatory-care settings. 

It is likely that as this specialty becomes filled with a 
higher proportion of residency-trained family physicians 
it will continue to gain status within the medical profes- 
sion. Data compiled by the AAFP show a steady growth 
in the number of family practice residency graduates, 
from 35 in 1970 to 2,359 in 1986, for a cumulative total of 
21,826. 9 In some situations, however, medical students 

may lack role models in family practice, because rela- 
tively few physicians in this specialty are located in an 
academic setting. Furthermore, some family practice 
rotations are scheduled too late in the medical school 
program, often after students have made their specialty 
choice. To ensure the continued growth of this specialty, 
family practice will need to continue its efforts to dissem- 
inate information about its attractions to all levels of the 
profession, particularly medical students. 

Beyond the scope of the medical profession, anecdotal 
information indicates that family physicians are faced 
with public misconceptions. There does not seem to be a 
widespread public understanding that family practice is a 
bona fide specialty. Although more and more patients 
are interested in having a single physician as the provider 
of primary care who treats the patient in the context of 
his or her family, there is a perception that this type of 
physician no longer exists. Public education campaigns, 
now in place, will likely contribute to an increased public 
awareness of the role, philosophy, and availability of 
family physicians and the continuity of services provided 
by such specialists to the patient and his or her family. 11 
Graduate Medical Education 

The emergence and rapid growth of the specialty of 
family practice were facilitated by federal, state, and 
private sector funding of residency training programs. In 
primarily rural and semirural states, such funding was 
often a direct response to strong political and legislative 
initiatives to address the need for more family physicians 
to replace the growing number of retiring general practi- 
tioners. From 49 approved residency programs in 1970 
with 290 residents, the numbers increased to 388 resid- 
ency programs in 1983 with 7,409 residents. In recent 
years the number of residency programs has declined 
slightly, to a total of 381 in 1986. The actual number of 
residents, however, has increased to 7,446. 9 As Table 4 

Table 4 

Family Practice Residency Programs by Program Structure in 1987* 



No. (%) 



of Programs 


Unaffiliated community hospital 

35 (9.2) 


University-affiliated community hospital 

209 (55.1) 


University-administered community hospital 

57 (15.0) 


University hospital 

63 (16.6) 


Military hospital 

15 (4.1) 


379 (100.0) 

*From American Academy of Family Physicians: Facts About 
Family Practice . 9 

demonstrates, just over half (55. 1%) of all family practice 
residency programs are in community hospitals affiliated 
with universities. 9 Family practice residency programs of 
excellent quality are frequently located in independent 
and/or community hospitals. One of the reasons family 
practice residency program directors have turned to 
independent and/or community hospitals for both resi- 
dency training positions and patient care opportunities 
has been the limited availability of funding for family 



practice residents in academic settings. The increasing 
i attractiveness of family practice is likely to serve as an 
■ impetus for the further development of family practice 
: residency programs in both the academic environment 
and the community hospital setting. 

It is the stated goal of family practice organizations to 
increase the number of family physicians. The intent of 
some recent legislative proposals that would reduce fed- 
eral funding for graduate medical education also has 
been to emphasize primary-care specialties, including 
family practice. These proposals would limit the number 
of years of graduate medical education to be funded by 
Medicare part A, “Support of Inpatient Services.” Such 
proposals would indirectly reduce the training of subspe- 
cialists and increase the number of primary-care resi- 
dency positions that could be funded. 

Funding for family practice education does face two 
obstacles: much of the specialty is ambulatory based, and 
many of the services provided by family physicians are 
nonprocedural. Training in an ambulatory care envi- 
ronment is an important element in the family practice 
curriculum. However, graduate medical education is 
supported as part of the cost of inpatient care. It is 
difficult to allocate inpatient income to support family 
practice residencies. Additionally, the teaching responsi- 
bilities of the attending physicians in ambulatory centers 
have made it difficult for some centers to support resi- 
dents primarily with income from patient fees. 

In general, primary-care education in an ambulatory- 
care setting generates lower revenues and higher costs. A 
contributing element is the fact that many of the services 
provided by the family practice resident are nonproce- 
dural, such as diagnosis and consultation. Nonprocedural 
services are currently reimbursed under the Medicare 
program at a lower rate than are procedural services. 
However, this situation is not static. Currently under 
development are a variety of proposed adjustments to 
physician reimbursement systems that have the potential 
to address this issue. 

At the national level, the perceived need for more 
primary-care physicians, particularly in rural areas, might 
support the efforts by family physicians to secure con- 
tinued funding for graduate medical education. The 
Consolidated Omnibus Budget Reconciliation Act (1986) 
established the federal Council on Graduate Medical 
Education (COGME), which is charged with assessing 
physician manpower needs on a long-term basis. In its 
first report to the Secretary of Health and Human Ser- 
vices and the Congress (July 1, 1988), COGME concluded 
that there is “an undersupply of physicians in family 
practice [Conclusion D-2].” It further identified that the 
“Council places the highest priority on reimbursement of 
residency training stipends and fringe benefit costs, train- 
ing in those primary care specialties which are in short 
supply . . . [Recommendation 16].” 12 This may pro- 
vide an opportunity for primary-care physicians, and 
family physicians in particular, to reaffirm their goals 

and resource needs. In addition to public funding at the 
national level, programs that were initiated at the man- 
date of state legislatures and/or are funded largely by 
states will actively need to seek opportunities to secure 
continued funding. 

Private foundations and voluntary health organiza- 
tions will continue to be limited resources, but family 
practice will need to expand its funding sources for 
graduate medical education. In recent years an increas- 
ing percentage of family practice residency graduates 
have practiced in alternative health care delivery sys- 
tems. 9 Managed-care systems are generating a demand 
for family physicians at a rate that might create a signifi- 
cant shortage in this specialty. Therefore, this specialty 
may wish to explore the question of corporate funding 
for family practice residency training programs. Such 
funding might provide positive incentives for both the 
resident physician and the managed care system. 


Reimbursement policies of third-party payers present 
challenges to family physicians in obtaining acceptable 
compensation and assuring appropriate access to care 
for their patients. Because an increasing proportion of all 
physician gross income is derived from third-party pay- 
ers, concerns generated by reimbursement systems are 
likely to continue for family physicians. 

Respondents to a 1987 AAFP survey indicated that 
37% of their patients had Medicare or Medicaid as their 
principal type of health insurance. The survey results 
also showed that over 39% of the patients were covered 
by other health insurance plans, including Blue Cross- 
Blue Shield and commercial plans, and 12% were covered 
under a prepayment/ capitation system. The remaining 
12% of family physicians’ patients had no protection 
against health expenses. 9 

The many reimbursement mechanisms currently in 
use by third-party payers have had ramifications for 
physicians in all specialties. The reimbursement issues 
most problematic for family physicians are the level of 
compensation for office visits, counseling, and other 
time-intensive services; specialty differentiation; geogra- 
phic differentiation; and the impact of all these factors on 
patient access to health care. 

As discussed earlier, a long-standing issue of concern 
to family physicians is the disparity in reimbursement for 
nonprocedural vs procedural services. A related issue is 
the determination of the “prevailing charge” for their 
services under the Medicare program. The prevailing 
charges for family physicians were determined in 1973. 
Because the specialty of family practice was relatively 
new at that time, prevailing charges were based on the 
charges of general practitioners. It is the position of the 
AAFP that the adjusted prevailing charges currently 
applied to family physicians are inappropriately low and 
do not accurately reflect the level of services provided by 
these specialists. 13 

VOLUME 53, NO. 2 


Prevailing charges are part of another issue pertinent 
to reimbursement, that of specialty differentiation. Some 
carriers base the level of reimbursement under Medicare 
for a particular service in part on the physician’s spe- 
cialty. Family physicians maintain that they are often 
adversely affected by this system. Family practice has 
joined with other primary-care specialties to call for a 
review of reimbursement, so that family physicians, who 
have the same customary charge for a service as physi- 
cians in other specialties, will be able to receive the same 
level of reimbursement. 

Geographic differentials in third-party reimbursement 
have also affected family physicians. Currently, rural 
physicians are reimbursed at lower levels than physicians 
practicing in metropolitan areas. The AAFP maintains 
that the data do not support the popular argument that 
the costs of supporting a practice are substantially less in 
rural areas. 13 

The potential implementation of new reimbursement 
mechanisms will have far-reaching implications for fam- 
ily physicians. The development of a resource-based rela- 
tive value scale is perhaps the most prominent of the 
proposals under consideration. The relative value scale 
study will assign numerical values or rankings to medical 
and surgical services based on variables that will include 
intensity, time, amortized opportunity costs of specialty 
training, and overhead. Primary-care physicians, espe- 
cially family physicians, will be monitoring this study 
with interest, as it may provide them with an opportunity 
to address the concerns described above. 

Because of the continuum of care they provide for 
their patients of all ages, family physicians have the 
potential to receive reimbursement under both Medicaid 
and Medicare as well as from other third-party payers. 
The increasing age of the US population will likely lead 
to more patients for family physicians who are covered 
under the Medicare program. 

Scope of Practice 

A practice profile survey conducted by the AAFP 
reveals that an overwhelming majority (approximately 
93%) of family physicians are engaged in direct patient 
care. Of these physicians, fewer than half participate in 
alternative modes of health care delivery (Table 3). 
Approximately 60% of all office visits to family physi- 
cians are made by women, with the greatest number of 
visits from women in their childbearing years. 9 This puts 
some family physicians in competition with obstetricians 
and gynecologists. 

The aging of the US population also has implications 
for the future of family practice. Even though family 
physicians provide a continuum of care throughout the 
life of the patient, there will likely be a noticeable shift in 
their services to accommodate the health care needs of an 
aging population. Anticipating this trend, the ABFP and 
the American Board of Internal Medicine are jointly 
sponsoring an examination for a certificate of added 
qualification in the specific clinical area of geriatrics. 

Another area that sometimes poses a challenge for 
family physicians involves obtaining hospital privileges 
in obstetrics and access to intensive care units. Many of 
these barriers are regional — urban vs rural — and reflect a 
direct relationship to the availability of physicians in 
other specialties in the same hospital. Even though some 
family physicians may be experiencing difficulties in 
obtaining a broad scope of hospital privileges at the 
hospital(s) of their choice, the demand for family physi- 
cians at hospitals is nationwide. According to a recent 
survey of all sizes of hospitals in five geographic regions 
(West, Midwest, Southwest, Southeast, and Northeast), 
family physicians are in the greatest demand. Only in the 
West was there a greater demand for obstetricians (20%) 
than for family physicians (19%). The highest demand is 
in the Midwest, where 40% of all responding hospitals 
indicated a need for family physicians. 14 

In many settings family physicians are in direct com- 
petition with other primary-care specialties to provide 
similar services. Additionally, as some medical special- 
ties increasingly employ high technology in their patient 
care (eg, cardiology), this may erode the level and amount 
of care a family physician can provide. Conversely, in- 
creased use of technology in some specialties may elevate 
the complexity of the procedures performed. This could 
result in a shift of more routine procedures from the 
specialist to the primary-care physician, broadening the 
scope of care of the family physician. 

Recent proposals have suggested combining family 
practice and internal medicine residency programs. 15 * 16 
However, such proposals are not universally supported. 
Eliminating the separate identities of general internal 
medicine and family practice would at present be unac- 
ceptable to both specialties. Nevertheless, several possi- 
bilities for cooperative efforts should be explored. A 
recent example of such a cooperative venture, mentioned 
above, was the development of a joint geriatric medicine 
certification process by the ABFP and the American 
Board of Internal Medicine. Additional opportunities 
for cooperative activities with other specialties include 
developing and obtaining funding for primary-care re- 
search, enhancing the status of primary-care academic 
faculty, improving reimbursement for primary-care ser- 
vices, and lobbying for primary-care objectives in the 
national political arena. 17 
Managed Care 

Closely aligned with any discussion of scope of prac- 
tice is the concept of managed care. In the traditional 
fee-for-service setting, this term has referred to the physi- 
cian who is able to assess the health care needs of the 
patient and provide a broad range of medical services to 
address those needs. This physician served as the pro- 
vider of primary care, referring the patient to different 
medical specialists as required. In recent years, this type 
of patient care has gained increased popularity in group 
practice settings and, particularly, in health maintenance 



The dramatic increase in managed-care systems in 
recent years has created a strong dertiand for family 
physicians. Continuity in the provision of care, which is 
the hallmark of this specialty, and the ability of family 
physicians to treat patients of all ages make them partic- 
ularly qualified to serve as case managers in managed- 
care systems. They are sought not only because they offer 
a broad range of services but also because they are 
perceived as cost-efficient utilizers of resources. Large 
multihospital and multisystem organizations have incen- 
tives to utilize resources efficiently, and family physicians 
might meet these needs by serving as “case managers.” 
Managed-care systems are able to offer incentives to 
family physicians, such as guaranteed income, marketing 
the physician’s services to the community, and providing 
office space, equipment, and personnel. 18 These incen- 
tives are particularly attractive to family physicians, who 
in 1986 spent more than half of their gross income on 
practice expenses. 7 In addition to the economic consid- 
erations, managed-care systems place additional value 
on disease prevention and health promotion, views strong- 
ly supported by all physicians. 

In short, managed care offers new opportunities for 
providers of primary care, such as family physicians. It is 
anticipated that the continued growth of managed-care 
systems will result in a strong demand for family physi- 
cians. This orientation in health care delivery is likely to 
provide an attractive spectrum of opportunities for pres- 
ent and future family physicians. 

Professional Liability 

In 1986, self-employed family physicians paid average 
premiums of $7,300 for professional liability insurance, 
an increase of 49.3% since 1982. As Table 5 demonstrates, 

Table 5 

Mean Professional Liability Premiums for Self-Employed Physicians* 

Type of Physician 

Mean Professional Liability 
Premium by Year, 
Thousands of $ 

1982 1983 1984 1985 1986 

All physicians 







General practice and 
family practice 






Internal medicine 


















Obstetrics and gynecology 






*From Gonzalex and Emmons (eds): Socioeconomic Characteris- 
tics of Medical Practice, 1987. 1 

premiums paid by family physicians closely correspond 
to those paid by physicians in the specialties of internal 
medicine. In comparison, physicians overall paid an 
average of $12,800 in professional liability insurance 
premiums in 1986 — a 45.3% increase since 1982. 7 

Because family practice encompasses a wide range of 
health care delivery, family physicians are vulnerable to 
many changes in trends in claims and premium rules. 

The AAFP estimates that in 1987 approximately 41% of 
family physicians included obstetrics in the scope of their 
services. 9 This percentage represents a dramatic decline 
from 1985, when, according to the AAFP Active Mem- 
ber Practice Profile Survey, approximately 54% of fam- 
ily physicians included obstetric services in their practice. 

The implications for both health care delivery and 
access are severe. Rural and underserved areas often 
look to primary-care physicians, particularly family phy- 
sicians, for most if not all of their medical needs. The 
current crisis in professional liability therefore affects 
both the patient and the physician and, if this crisis 
continues unabated, the implications for patient care will 
be severe. 


Data on self-designated specialties collected by the 
AM A Physician Masterfile indicate that between 1975 
and 1986 the overall active physician population in- 
creased by almost 45%. 5 In contrast, the active family 
physician population, including general practitioners, 
grew by only 24%. During the next 15 years the AM A 
projects that the total physician population will increase 
by nearly 22%, while the number of family physicians is 
projected to increase by only 9%, to a total of 74,600 by 
the year 2000 (Fig 3). 19 In comparison, the US Census 

and Medicine Gynecology 



Figure 3 

Projected physician population by specialty in 1990 and 2000 (from 
Marder and colleagues: Physician Supply and Utilization by Specialty: 
Trends and Projections l9 ). 

Bureau projects that the US population will increase by 
12.3% between 1985 and 2000. 19 Given these projections, 
it is possible that the supply of family physicians may not 
meet the demand for their services. 

A significant characteristic of this specialty is the var- 
iance in age, particularly when this variance is correlated 
with the self-designation of family physician or general 
practitioner. In 1986, approximately 63% of all general 
practitioners were over the age of 55 years, and almost 
one third were over the age of 65 years. In contrast, in 
1986, over two thirds of all family physicians were under 

VOLUME 53, NO. 2 


the age of 45 years, and approximately 36% were under 
35 years of age. 5 Between now and the turn of the century 
there will be further dramatic declines in the number of 
self-designated general practitioners and a continued 
concentration of family physicians in the younger age 

Four factors have serious implications for the future 
of family practice manpower: 

• There has not been a significant increase over the last 
few years in the number of family practice residency 
program graduates. 

• The number of general practice physicians retiring 
from medicine will increase. 

• Managed-care systems will increase the demand for 
family physicians as case managers, but as yet they have 
not funded or developed residency training programs to 
generate more family physicians to meet the demand. 

• The projected growth of other primary-care special- 
ties, such as internal medicine, pediatrics, and obstetrics 
and gynecology, and the projected overall surplus of 
physicians will increase the level of competition. 

These are some of the questions that can be posed with 
respect to family physician manpower: Will the demand 
created by managed-care systems further erode the num- 
bers of family physicians available for other types of 
practice? Will rural and other underserved areas con- 
tinue to experience a shortage of family physicians? Will 
continued growth in the number of family physicians 
and the likelihood for increased competition among all 
primary-care specialties have a positive or negative effect 
on the environment of family practice? 

There will continue to be constraints on the profession 
of family practice, such as those related to the scope of 
practice, professional liability, and others discussed ear- 
lier in this report. However, the strong demand for fam- 
ily physicians has positive ramifications for the future of 
this specialty. 

Ethical and Societal Issues 

Unresolved social and ethical issues will continue to 
shape health care delivery for all physicians. As provid- 
ers of care from before birth to death, family physicians 
in particular have the potential to be confronted by the 
entire range of ethical issues facing the medical profes- 
sion. It is expected, for example, that medical technology 
will continue to advance at a rapid pace. In light of this, 
ethical issues surrounding withholding or withdrawing 
life-prolonging medical treatment — for patients of any 
age — will present ongoing dilemmas for family physi- 
cians. However, the mandate to “serve as the patient’s or 
family’s advocate in all health-related matters” requires 
family physicians to participate in the resolution of these 
ethical dilemmas. 

Additionally, as the physician who makes the initial 
diagnosis and provides the continuum of care, the family 
physician will need to cope with the broad range of social 
and health crises, such as the marked increase in teenage 

pregnancy, infant mortality, and the spread of the human 
immunodeficiency virus. Because of their commitment 
to the patient and the family, family physicians need to 
keep current on the information and issues that contrib- 
ute to the ethical and societal milieu in which they pro- 
vide patient care, and, in many instances, they need to be 
prepared to serve as coordinators of ethical decision 

Family physicians, because of their role in the life- 
styles of their patients, also are involved in health and 
societal issues that affect the well-being of their patients. 
Ongoing concerns regarding occupational and environ- 
mental health as well as preventive health care measures 
have the potential to claim a larger role in the practices of 
family physicians. At present, for example, many family 
physicians are working with the AAFP and the AM A to 
bring about a smoke-free society. 

As changing circumstances, such as the increased uti- 
lization of sophisticated health care technology, broaden 
the range of ethical issues, it will be important for gradu- 
ate and postgraduate family practice medical education 
to keep pace. In addition to participating in the ethical 
decision-making process, family physicians have an oppor- 
tunity in this dynamic health care environment to serve 
as their patients’ and families’ advocates. Family physi- 
cians, because of the level of their involvement, are in a 
position to represent the needs and interests of their 
profession and their patients in the ongoing debate over 
the delivery of health care. 

Implications for the Future 

In summary, the following factors are likely to influ- 
ence the future socioeconomic environment of family 

• There could be a positive change in the status of 
family physicians within the medical profession, and the 
public will become more aware of the role of and need 
for family physicians. 

• There may be a broadening of the sources of funding 
for residency training programs, particularly those that 
involve corporate funding. 

• There is the potential for an increase in the demand 
for family physicians’ services, particularly as society 
places greater emphasis on continuity of care, preventive 
medicine, and health promotion. 

• The demographics of the US population will change, 
including, most notably, a shift toward the health care 
needs of an older age group. 

• The demand for family physicians may increase, par- 
ticularly in managed-care settings, to utilize their broad 
range of health care services and their skills as case 

• There may be a shortage of family physicians, despite 
a predicted oversupply of physicians in general, particu- 
larly in managed-care systems and in rural areas that are 

• Some aspects of family practice (eg, obstetrics) that 



involve high professional liability insurance premiums 
may be further curtailed. 

• Family practitioners will have an increased role in 
formulating and resolving ethical issues as they pertain 
to patients and their families. 

The opportunities for family physicians clearly out- 
weigh the constraints. Nonetheless, there are several 
avenues by which the medical profession can help ensure 
a favorable future practice environment: 

1. The medical profession can continue to educate the 
public on the role and function of the family physician, 
the available forms of health care delivery, and health 
promotion and disease prevention. 

2. The medical profession can promote and maintain 
high standards among physicians who practice family 
medicine by increasing the awareness of patients and 
physicians regarding ethical and bioethical decision mak- 
ing and by continuing to provide high-quality continuing 
medical education opportunities. 

3. The medical profession can assume a leadership role 
by working with all the primary-care specialties to assure 
that quality health care is available in rural areas by 
supporting hospitals and physicians in those areas. 

4. The medical profession can provide advocacy for the 
specialty of family practice by actively promoting the 
image and status of the family physician at all levels of 
the medical profession. 

5. The medical profession can aggressively represent 
family practice at all levels of government and with all 
federal, state, and community agencies, be they public or 
private. Furthermore, the medical profession can work 
to assure that family physicians have access to affordable 
professional liability insurance and that they are treated 
fairly regarding reimbursement issues. 

6. The medical profession must strive to ensure that 
family practice residency programs, in whatever setting, 
are of the highest quality and that graduates of these 
programs have been trained to deal with the complex 
ethical issues they will face throughout their professional 


1 . Council on Long Range Planning and Development: The Envir- 
onment of Medicine. Chicago, American Medical Association, 

2. Family Practice: Creation of a Specialty. Kansas City, Mo, Ameri- 
can Academy of Family Physicians, 1980. 

3. Committee on Preparation for General Practice: Report of the 
Board of Trustees, in Proceedings of the House of Delegates, June 
8-12, 1959. Chicago, American Medical Association, 1959, pp 

4. Ad Hoc Committee on Education for Family Practice: Meeting 
the challenge of family practice: Council on Medical Education 
report A, in Proceedings of the House of Delegates, November 
28-30, 1966. Chicago, American Medical Association, 1966, pp 

5. Roback G, Mead L, Randolph L: Physician Characteristics and 
Distribution in the US. Chicago, American Medical Association, 

6. National Ambulatory Medical Care Survey: 1985 Summary, US 
Dept of Health and Human Services publication (PHS) 128, cited 
by American Academy of Family Physicians: Facts About Family 
Practice. Kansas City, Mo, Burd & Fletcher Co, 1987. 

7. Gonzalez M, Emmons D (eds): Socioeconomic Characteristics of 
Medical Practice, 1987. Chicago, American Medical Association, 

8. Cogswell B, Sussman M: Family Medicine: A New Approach to 
Health Care. New York, Haworth Press Inc, 1982. 

9. American Academy of Family Physicians: Facts About Family 
Practice, Kansas City, Mo, Burd & Fletcher Co, 1987. 

10. Perkoff G: The research environment in family practice. J Fam 
Pract 1985;21:389-93. 

11. AAFP president predicts bright future for FP specialty at SOC. 
A AFP Rep, May 1987, p 1. 

12. Council on Graduate Medical Education: First Report, Volume I, 
Executive Summary. US Dept of Health and Human Services, 
July 1, 1988, pp xxi-xxvii. 

13. Hearings Before the Health Subcommitee on Medicare Physician 
Payment of House Ways and Means Committee, 100th Cong, 3 1st 
sess (1987) (testimony of Robert Graham, MD, of the American 
Academy of Family Physicians). 

14. Riffer J: Family physicians are in greatest demand now. Hospitals 

15. Christainsen R, Johnson LP, Boyd G, et al: A proposal for a 
combined family practice — internal medicine residency. JAMA 

16. Geyman J: Training primary care physicians for the 21st century. 
JAMA 1986;255:2631-35. 

17. Friedman R: Family practice and general internal medicine: What 
kind of cooperation makes sense? JAMA 1986;255:2644-46. 

18. Horwitz N: For-profit demand drying up FP pool. Med Trib, 
April 1, 1987, pp 1, 12-13. 

19. Marder W, Kletke P, Silberger A, et al: Physician Supply and 
Utilization by Specialty: Trends and Projections. Chicago, Ameri- 
can Medical Association, 1988. 

VOLUME 53, NO. 2 


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Combination Antiarrhythmic Therapy 


C OMBINATION therapy with antiarrhythmic agents 
is often used when therapy with a single agent is 
ineffective or only partially effective. 1 Additionally, ther- 
apy with a single antiarrhythmic agent may be poorly 
tolerated at doses required to prevent arrhythmias or to 
treat them effectively. Antiarrhythmic drug combina- 
tions may be better tolerated than single-agent regimens, 
because individual drug doses may be lower than those 
necessary when either agent is used alone. 2 Antiarrhyth- 
mic drug combinations are usually selected based on 
knowledge of the Vaughan Williams classification of 
antiarrhythmic agents 3 (Table 1) and the electrophysio- 
logic properties of the agents. The purpose of this paper 
is to review the advantages and potential toxicities of 
commonly used combinations of antiarrhythmic drugs. 
Class IA and IB Combinations 
Class I antiarrhythmic agents bind to sodium channels 
in myocardial cells and inhibit fast inward sodium cur- 
rent, thereby reducing the maximum rate of depolariza- 
tion without affecting resting membrane potential. 1 * 2 
The affinity of individual antiarrhythmic agents for the 
sodium channels varies depending on whether the chan- 
nels are in the resting (phase 4), open (activated, phase 0), 
or inactivated (repolarizing) phase. Class IA agents bind 
with greater affinity to open channels, for example, 
whereas class IB agents bind to open and inactivated 
channels with equal affinity. 4 Therefore, blockade of 
frequency-dependent sodium channels with a combina- 
tion of class IA and IB antiarrhythmic agents may be 
additive. Combinations of agents from these classes may 
have additive effects on conduction velocity and refrac- 
tory period, and class IB agents may normalize pro- 
longed QT intervals induced by class IA agents. 5 

JAMES E. TISDALE, PHARM.D., Clinical Pharmacy Fellow, 
Cardiovascular Therapeutics, Hartford Hospital; Assistant Clinical 
Professor, University of Connecticut, School of Pharmacy, Storrs, CT. 

This series on Drug Information Updates from Hartford Hospital is 
provided by the Drug Information Center, Department of Pharmacy 
Services, Hartford Hospital. 

Editors: Moses Sing Sum Chow, Pharm.D., and Robert A. Quercia, 
M.S., R.Ph. 

The most commonly used combination of class IA 
and IB antiarrhythmic agents is that of quinidine and 
mexiletine, and the efficacy of this combination has been 
evaluated in a number of studies (Table 2). 5-15 These 
studies demonstrate that this combination may be effec- 
tive in patients with ventricular arrhythmias in whom 
therapy with either agent alone has failed. Quinidine has 
also been used successfully in combination with tocai- 
nide for suppression of ventricular arryhthmias. 16 * 17 Suc- 
cess rates with the combination of mexiletine and pro- 
cainamide in patients with ventricular arrhythmias refrac- 
tory to either agent alone have been similar to those 
determined using the quinidine-mexiletine combina- 
tion. 9-15 Mexiletine has also been used successfully with 
disopyramide. 8 * 10 * 11 , 13-15 , 18 Experience with tocainide in 
combination with either procainamide or disopyramide 
is limited. 19 Further study is required to determine the 
efficacy of tocainide in combination with these agents. 

Based on data reported in a number of studies (Table 
2) it appears that combination therapy with class I A and 
IB agents may be effective in approximately 20% of 
patients in whom single-agent therapy is unsuccessful, 2 
and this combination may be associated with a lower 
incidence of extracardiac toxicity than use of single 
agents at higher doses.WV 9 

Class IA and IC Combinations 

Experience with combinations of class IA and IC 
agents is limited. Agents in both groups reduce ventricu- 
lar conduction velocity, thereby prolonging the QRS 
interval. Additionally, class IA agents prolong repolari- 
zation, thereby prolonging the JT (QT-QRS) interval. 
Therefore, it might be anticipated that combinations of 
drugs from these two classes may have considerable 
proarrhythmic potential, and may cause additive unde- 
sirable effects on the electrocardiogram. 2 Klein et al 20 
evaluated the efficacy of an investigational class IC 
agent, propafenone, in combination with quinidine or 
procainamide for patients with ventricular arrhythmias 
refractory to the class IA agent alone (Table 2). The 
addition of propafenone to quinidine or procainamide 

VOLUME 53, NO. 2 


resulted in statistically significant prolongation of PR, 
QRS, and QT intervals compared with class IA or pro- 
pafenone monotherapy; two patients (6%) experienced a 
probable proarrhythmic effect when propafenone was 
added to their class IA regimen. 

There is no available literature evaluating encainide or 
flecainide in combination with class IA antiarrhythmic 

Table 1 

Modified Vaughan Williams Classification of Antiarrhythmic Agents 3 

Class I - Sodium channel blocking agents 

A. Quinidine 

B. Lidocaine 

C. Encainide 

Class II - Adrenergic beta-receptor blocking agents 

Class III - Inhibitors of repolarization 

Class IV - Calcium channel blocking agents 

Class I and Class II Combinations 

Adrenergic beta-receptor blocking agents (beta-block- 
ers) antagonize the electrophysiologic effects of catecho- 
lamines. 21 Catecholamines increase the rate of mem- 
brane depolarization, reversing the depression of phase 0 
of the cardiac action potential that is induced by class I 
antiarrhythmic agents. Antagonism of this effect with 
beta-blockers may increase the potential for class IA 
agents to depress excitability, increase conduction time, 
and prolong the refractory period. 22 

The most commonly reported combination of class I 
and II antiarrhythmic agents is that of quinidine and 
propranolol, which may be effective at controlling re- 
fractory supraventricular 23 * 24 and ventricular 24-26 arrhyth- 
mias. Results of some studies combining Class I A agents 
and beta-blockers 23-27 are reported in Table 2. Combina- 
tions of beta-blockers with class IB agents have also been 
used successfully to treat refractory ventricular arrhyth- 
mias (Table 2). 19 * 28 Further study is required to establish 
the efficacy of combinations of class IB and class II 

Experience with combinations of class IC and class II 
agents is limited. Evidence suggests that use of a class IC 
agent in combination with propranolol offers no advan- 
tage for control of ventricular arrhythmias compared 
with the beta-blocker alone (Table 2). 26-29 

Class I and Class III Combinations 

Combinations of class I agents with amiodarone have 
been used in patients who have failed to respond to any 
other mode of therapy. Amiodarone has been used in 
combination with quinidine, procainamide, and disopy- 
ramide, both for prevention of ventricular arrhythmi- 

as 30 - 33 and for maintenance of sinus rhythm after cardi- 
oversion of atrial fibrillation. 32 * 34 Amiodarone has also 
been used in combination with mexiletine for control of 
ventricular arrhythmias. 31 * 35-37 Based on data reported in 
these studies, the combination of amiodarone and a class 
I A or IB agent may prevent ventricular arrhythmias and 
atrial fibrillation in some patients refractory to conven- 
tional therapy. Experience with the combination of ami- 
odarone and class IC agents is limited (Table 2). 38 Further 
study is required to evaluate this combination. 

Combinations with Class IV Agents 

Combination therapy with calcium channel blocking 
agents for arrhythmia control has not been extensively 
studied. The combination of verapamil and quinidine 
may be effective in preventing atrial fibrillation in patients 
refractory to quinidine alone. 2 The antiarrhythmic effi- 
cacy of verapamil 39 and diltiazem 40 in combination with 
propranolol has been evaluated. These combinations 
have been effective in treating some patients with parox- 
ysmal supraventricular tachycardia (PSVT) (Table 2). 
Further study is necessary to establish the efficacy of 
combination therapy with calcium channel blocking 

Other Antiarrhythmic Combinations 

Combinations of class I A antiarrhythmic agents may 
facilitate use of lower doses of the respective agents and 
reduce the incidence of adverse effects. 41 * 42 Simultaneous 
use of two agents from this group may be successful in 
some patients, but the risk of proarrhythmic effects of 
this combination may outweigh potential benefits, par- 
ticularly in view of the fact that many new antiarrhyth- 
mic agents have become available. 2 

There is no reported experience with combinations of 
class II and class III agents. Because amiodarone has 
electrophysiologic effects similar to those of beta-block- 
ing agents, 43 this combination may have an additive 
effect on sinus node automaticity and atrioventricular 
conduction, and therefore may not be tolerated by some 
patients. 1 

Drug Interactions 

Combinations of class IA agents, as well as combina- 
tions of amiodarone and class IA agents, may result in 
prolongation of the QT interval and torsades de poin- 
tes . f 44 Drugs that have considerable negative inotropic 
effects, notably beta-blockers, calcium channel blockers, 
disopyramide, and flecainide should be used carefully in 
combination, particularly in patients with left ventricular 

A number of pharmacokinetic interactions have been 
reported. Quinidine has been shown to elevate steady 
state serum procainamide concentrations approximately 
70%. 45 Propranolol has been shown to increase serum 
flecainide concentrations by 25%. 29 * 46 Amiodarone is 
known to increase serum quinidine and procainamide 
concentrations. 47 * 48 



Table 2 

Synopsis of Studies Evaluating Combinations of Antiarrhythmic Agents 





Method of 


Type of 










Agent(s) Failed 

ft Pis. (%) 

# Pts. (%) 










M= 1/20(5) 
Q+M=7/ 20(35) 









Q+M= 16/ 17(94) 

Q+M= 10/ 14(71) 








Q+M=7/35 (20) 





Q; D+M 










Q / PA+M 



Q/ PA/M 


M=0/ 23(0) 
Q/PA+M=8/ 23(235) 









M=7/ 23(30) 




Other = NA 









PA= 24/ 70(34) 
PA+M=4/ 15(27) 



Q/ PA+M 







Other = NA 



Q/PA/ D+M 




M=29/ 128(23) 

M=20/ 30(67) 


IA+M=48/ 1 1 1(43) 

IA+M= 50/ 62(81) 







IA=37/ 127(29) 


IB= 13/ 127(10) 
IA+IB= 20/ 127(16) 



Q/PA/ D+M 




IA+M=2/ 15(13) 


Q/PA/ D+M 



IA+M=7/ 29(24) 







T=2/ 13(15) 
Q=3/ 13(23) 
T+Q=6/ 13(46) 









T=6/ 20(30) 
Q+T= 16/ 20(80) 









D=6/ 12(50) 



M=4/ 12(33) 
D+M=8/ 12(66) 








T=6/ 10(60) 

T= 1/10(10) 





D+T= 1/2(50) 

IA + IC 



Q/PA + 






Q/ PA+ Propaf 16/ 23(70) 

1 + II 







Q+P=8/ 13(62) 



A.fib/ flutter 

P=8/ 34(24) 
Q+P= 12/ 33(36) 


P=3/ 12(25) 
Q+P=8/ 11(73) 



Q / PA+P 















Q/ PA+N 












VPB’s, couplets 


P=7/ 10(70) 


P+F=6/ 10(60) 

I + III 



Q/ PA+A 





A= 16/20(80) 



A+P= 15/20(75) 

VOLUME 53, NO. 2 


Table 2 (Cont.) 

Synopsis of Studies Evaluating Combinations of Antiarrhythmic Agents 



Method of 




Type of 

Agent(s) Failed 

it Pts. (%) 

it Pts. (%) 










Q/M+A=9/ 1 1(82) 





A+Class IA 



A.Class IA 

A=8/ 10(80) 








A, Class IA 

A=6/ 32(19) 
A+IA= 14/ 26(54) 










A=0/ 2(0) 









A=0/ 10(0) 

M=0/ 10(0) 

A+M= 10/ 10(100) 











A+F=l 1/24(46) 


up to 
3 yrs 

11 + IV 





V/ P, 
Class I 

V=7/ 13(54) 
P=4/ 13(31) 
V+P=l 1/13(85) 











Di+P= 14/ 15(93) 
Placebo=4/ 15(27) 



* While the arrhythmia only became non-inducible in two patients on this combination the mean ventricular tachycardia cycle length (VTCL) was 
significantly greater on the combination, and 16/ 3 1(52%) of patients on the combination were hemodynamically stable during VT, compared with 
10/37(27%) on A alone. 

I A = class I A agent 
A = amiodarone 
D = disopyramide 
Di =diltiazem 
E = encainide 
F = flecainide 
L = lidocaine 
M = mexiletine 
N = nadolol 

/ = or 

P = propranolol 
PA = procainamide 
Propaf. = propafenone 
Q = quinidine 
T = tocainide 
V = verapamil 

AE = ambulatory electrocardiography 
A.fib = atrial fibrillation 
A.flut = atrial flutter 

AT = atrial tachycardia 

EPS = electrophysiology studies 

NA = information not available 

NSVT = nonsustained ventricular tachycardia 

PSVT = paroxysmal supraventricular tachycardia 

S-VT = sustained ventricular tachycardia 

VEA = ventricular ectopic activity 

VF = ventricular fibrillation 

VPB’s = ventricular premature beats 


Combination antiarrhythmic therapy may be benefi- 
cial for treatment of arrhythmias refractory to single 
agents, or in cases where required doses of single anti- 
arrhythmic drugs cannot be tolerated. It should be em- 
phasized that combinations of antiarrhythmic agents 
should be used only after treatment with adequate doses/ 
serum concentrations of single agents has failed. Ther- 
apy should be individualized based on the patient’s age, 
type and severity of arrhythmia, and concomitant di- 
sease status, particularly with reference to liver, kidney, 
and left ventricular function. Electrophysiologic testing 
is recommended to guide the selection of appropriate 
therapy for patients with malignant ventricular arrhyth- 
mias, and for those patients who may be at risk for 
sudden cardiac death. 15 ’ 49-51 


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2. Krichbaum DW: Combination drug therapy for ventricular arrhyth- 
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3. Vaughan Williams EM: A classification of antiarrhythmic actions 
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4. Hondeghem LM, Katzung BG: Antiarrhythmic agents: the modu- 
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5. Duff HJ, Mitchell LB, Manyari D, Wyse DG: Mexiletine-quini- 
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23. Bekes M, Bajkay G, Maklari E, Torok E: Combined application of 
quinidine and propranolol for restoration and maintenance of 
sinus rhythym in supraventricular arrhythmias. Int Z Klin Phar- 
makol Ther Toxikol 1980;3:163-6. 

24. Fors WJ, Vanderark CR, Reynolds EW: Evaluation of propra- 
nolol and quinidine in the treatment of quinidine-resistant ar- 
rhythmias. Am J Cardiol 1971;27:190-4. 

25. Dreifus LS, Lim HF, Watanabe Y, McKnight E, Frank MN: 
Propranolol and quinidine in the management of ventricular 
tachycardia. JAMA 1968;204:190-1. 

26. Ross DL, Sze DY, Keefe DL, Swerdlow CD, Echt DS, Griffin JC, 
et al: Antiarrhythmic drug combinations in the treatment of ven- 
tricular tachycardia. Efficacy and electrophysiologic effects. Circu- 
lation 1982;66:1205-10. 

27. Deedwania PC, Olukotun AY, Kupersmith J, Jenkins P, Golden 
P: Beta blockers in combination with class I antiarrhythmic 
agents. Am J Cardiol 1987;60:21D-26D. 

28. Leahy EB, Heissenbuttel RH, Giardina EGV, Bigger JT: Com- 
bined mexiletine and propranolol treatment of refractory ventricu- 
lar tachycardia. Br Med J 1980;281:357-8. 

29. Stern H, Scheininger M, Theisen F, Theisen K: Antiarrhythmic 
therapy with flecainide in combination and comparison with pro- 
pranolol. Drugs 1985;29(Suppl. 4):77-85. 

30. Marchlinski FE, Buxton AE, Miller JM, Vassallo JA, Flores BT, 

Josephson ME: Amiodarone versus amiodarone and a type IA 
agent for treatment of patients with rapid ventricular tachycardia. 
Circulation 1986;74:1037-43. 

31. Hoffman A, Follath F, Burchhardt D: Safe treatment of resistant 
ventricular arrhythmias with a combination of amiodarone and 
quinidine or mexiletine. Lancet 1983;1:704-5. 

32. James MA, Papouchado M, Vann Jones J: Combined therapy 
with disopyramide and amiodarone. A report of 1 1 cases. Int J 
Cardiol 1986;13:248-52. 

33. Waxman HL, Groh WC, Marchlinski FE, Buxton AE, Sadowski 
LM, Horowitz LN, et al: Amiodarone for control of sustained 
ventricular tachycardia. Am J Cardiol 1982;50:1066-74. 

34. Brodsky M, Allen B, Ferguson C, Henry W: Amiodarone plus 
type IA antiarrhythmic drugs for the treatment of refractory atrial 
fibrillation (abstract). J Am Coll Cardiol 1985;5:480. 

35. Bellocci F, Santarelli P, Montenero A, Gianolla F, Nobile A: 
Value of electrophysiologic testing of amiodarone alone or in 
combination with class I antiarrhythmic drugs for ventricular 
tachycardia (abstract). Circulation 1985;72(Suppl. III):III-274. 

36. Waleffe A, Mary-Rabine LM, Legrand V, Demoulin JC, Kulber- 
tus HE: Combined mexiletine and amiodarone treatment of refrac- 
tory recurrent ventricular tachycardia. Am Heart J 1980; 100: 

37. Bellocci F, Santarelli P, Montenero AS, Scabbia E, Sandric S, 
Loperfido F: Combined administration of amiodarone and mex- 
iletine for refractory ventricular tachycardia (abstract). Eur Heart 
J 1984; 1:286. 

38. Frank R, Fontaine G, Tonet JL, Grosgogeat Y: Treatment of 
severe chronic ventricular arrhythmias by flecainide combined 
with amiodarone (abstract). Eur Heart J 1984;5(Suppl. 1): 18 1 . 

39. Yee R, Gulamhusein SS, Klein GJ: Combined verapamil and 
propranolol for supraventricular tachycardia. Am J Cardiol 1984; 

40. Yeh SJ, Lin FC, Chou YY, Hung JE, Wu D: Termination of 
paroxysmal supraventricular tachycardia with a single oral dose of 
diltiazem and propranolol. Circulation 1985;71:104-9. 

41. Duffy CE, Swiryn S, Bauernfeind RA, Strasberg B, Palileo E, 
Rosen KM: Inducible sustained ventricular tachycardia refractory 
to individual class I drugs: effects of adding a second class I drug. 
Am Heart J 1983;106:450-8. 

42. Kim SG, Seiden S W, Matos JA, Waspe LE, Fisher JD: Combina- 
tion of procainamide and quinidine for better tolerance and addi- 
tive effects for ventricular arrhythmias. Am J Cardiol 1985;56:84-8. 

43. Singh BN, Vaughan Williams EM: The effect of amiodarone, a 
new anti-anginal drug, on cardiac muscle. Br J Pharmacol 1970;39: 

44. Marcus FI: Drug interactions with amiodarone. Am Heart J 

45. Hughes B, Dyer JE, Schwartz AB: Increased procainamide plasma 
concentrations caused by quinidine: a new drug interaction. Am 
Heart J 1987; 1 14:908-9. 

46. Lewis GP, Holtzman JL: Interaction of flecainide with digoxin 
and propranolol. Am J Cardiol 1984;53:52B-57B. 

47. Tartini R, Steinbrunn W, Kappenberger L, Meyer UA: Dangerous 
interaction between amiodarone and quinidine. Lancet 1982; 

48. Saal AK, Werner JA, Greene HL, Sears GK, Graham EL: Effect 
of amiodarone on serum quinidine and procainamide levels. Am J 
Cardiol 1984;53:1264-7. 

49. Podrid PJ: Treatment of ventricular arrhythmia: applications and 
limitations of noninvasive vs invasive approach. Chest 1985; 
88 : 121 - 8 . 

50. Kim SG: The management of patients with life-threatening ven- 
tricular tachyarrhythmias: programmed stimulation or Holter 
monitoring (either or both)? Circulation 1987;76:1-5. 

51. Waller TJ, Kay NR, Spielman SR, Kutalek SP, Greenspan AM, 
Horowitz LN: Reduction in sudden death and total mortality by 
antiarrhythmic therapy evaluated by electrophysiologic drug test- 
ing: criteria of efficacy in patients with sustained ventricular 
tachyarrhythmia. J Am Coll Cardiol 1987;10:83-9. 

VOLUME 53, NO. 2 





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The Connecticut State Joint Practice Committee 


T HE Connecticut State Joint Practice Committee 
was established in 1972 by the Connecticut State 
Medical Society and the Connecticut Nurses’ Associa- 
tion. It is a liaison Committee of physicians (who collec- 
tively comprise the Committee on Allied Health Serv- 
ices) and nurses, whose members are appointed by the 
parent organizations and who are drawn from private as 
well as hospital practice. 

The Committee’s objectives are similar to those of the 
National Joint Practice Commission which preceded it. 
These include: 

1. The promotion of more effective communication 
among physicians and nurses. 

2. The promotion of comprehensive planning and pro- 
vision of optimal health services, regardless of deliv- 
ery setting or practice structure, through interprofes- 
sional collaboration among physicians and nurses. 

3. The identification of problems associated with ad- 
justments of the basic roles of the two professions, as 
well as suggestions concerning feasible solutions. 
Over the course of the past 17 years the committee has 
been involved in a variety of activities directed at further- 
ing its objectives. It has assisted Connecticut’s hospitals 
through workshops and invitational meetings in their 
efforts to establish their own hospital joint practice 
committees (presently at least 28 Connecticut hospitals 
have joint practice committees). It has examined issues 
such as the development of collaborative practice mod- 
els, and has written position statements on collaborative 
education of medical and nursing students, principles of 
licensure for health care personnel, and development of 
criteria for establishing new categories of health care 
workers. It has discussed the development of policies 
concerning “Do Not Resuscitate” orders, “Living Wills,” 
and “Death With Dignity.” It has been monitoring the 
issue of cost-containment and its effects on quality of 
care, as well as the origins, magnitude, and implications 
of the nursing shortage. 

Hospital joint practice committees have been involved 
in examining similar issues as well as the more tangible, 
clinical aspects of providing daily quality care. Specific 
issues addressed at the hospital level have included delin- 
eation of privileges for nurse practitioners and physi- 
cian’s assistants, development of “Do Not Resuscitate” 
criteria and policies, and establishment of policies for 
topics such as reintubation of extubated patients, or 

MARY B. PRYBYLO, R.N., M.S.N., Director of Nursing for 
l Medical, Surgical, and Psychiatric Services, St. Mary’s Hospital, 
Waterbury, CT., and ROBERT D. STEIN, M.D., Internist and Staff 
Physician, Gaylord Hospital, Wallingford, CT. Co-Chairpersons, The 
Connecticut State Joint Practice Committee. 

responsibilities and restrictions relative to the adminis- 
tration of I.V. medications. Ethical issues have been 
discussed at this level as well, and some hospital joint 
practice committees have spawned ethics committees to 
lend further assistance and guidance to administrators, 
nurses, and physicians who have been confronted with 
related problems. 

The State Joint Practice Committee is the only per- 
manent, formal organization of its kind within the state, 
where representatives from the Connecticut State Medi- 
cal Society and Connecticut Nurses’ Association can 
work together on a regular basis. Such a forum for 
communication appears to be even more important now 
than it was 17 years ago, especially in the current atmos- 
phere of intensified, and occasionally adversarial, com- 
petition among health care providers and institutions, 
the nursing shortage, and third-party efforts to usurp 
control of our patients’ care. 

There is concern that without adequate communica- 
tion and cooperation between the two professions, the 
situation will only deteriorate further, leading to in- 
creased friction between physicians and nurses, more 
fragmented, lower quality care, and greater dissatisfac- 
tion among health care providers. 

Current controversies include recent proposals for 
prescriptive authority for nurses, and for the develop- 
ment of registered care technologists. These, however, 
are but two of a growing number of issues that threaten 
to affect our practices and our attitudes towards one 
another, and that will most likely find their way to the 
legislature for refinement and approval. 

Many of us believe that now, more than ever, there is a 
need for our two professions to stand together against 
those issues that threaten our very existence, rather than 
to allow a chasm to develop between us. It is for this 
reason that the dialogue must continue, and it is for this 
reason that logical, rational compromises must be 
reached. Our focus, after all, is delivery of the best avail- 
able care to our patients. From this, all else follows. 
Without this we cease to be true professionals. 

Our committee members therefore believe that it is 
imperative that we continue to meet on a regular basis in 
order to enhance the dialogue within our state. Issues 
must be addressed, a broad spectrum of opinion will be 
sought, and recommendations will be provided to our 
parent organizations. 

Those who are able to participate are invited to do so, 
and may contact us through either the Connecticut 
Nurses’ Association or the Connecticut State Medical 
Society. Your efforts and involvement will be appre- 
ciated by all of us, but most especially by our patients. 

VOLUME 53, NO. 2 


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Shoot Out at the RBRYS Corral 


J UST about everyone agrees that the most hotly 
debated, discussed, and contested issue in many 
years, has been the matter of the “RBRVS” (Resource- 
Based Relative Value Scale, also known as the Hsiao 
Harvard Relative Value Study.) Undoubtedly, there will 
be many versions, interpretations, and other articles 
regarding this matter in view of its great impact upon 
how medicine will be practiced. In this article, I will try to 
put in what I believe to be the most important elements 
of this discussion. While this will not be quite a “fast 
take” article, I will attempt to lean in that direction. 

Many of you have read articles by a Harry Schwartz, 
Ph.D., a perceptive and excellent commentator on the 
medical scene. Unlike much of the media, he has been 
sympathetic toward American medicine and American 
doctors. We have a speaking acquaintanceship and I 
mentioned to him at the recent Dallas AMA meeting 
that “I could hardly wait to see what he was going to 
write in this matter.” He answered that “he could hardly 
wait to see what he, himself, was going to write.” Since I 
began this article he has, indeed, gone ahead with his 
incisive remarks published in Private Practice , January 
1989. He observes that “perhaps the most influential 
speaker on the RVS issue is Nelson Richards, M.D., a 
Virginia neurologist, who represented his specialty in 
discussions with Dr. Hsiao conducted a week before the 
, Dallas meeting. Dr. Richards reported that the Hsiao 
. team has been radically affected by the firestorm of 
1 physician criticism that has spread in response to its 
initial findings. He said Hsiao has pledged that his group 
will do a better job of its remaining work. Based on Dr. 
Richards’ comments, many delegates who were outraged 
by the initial Hsiao report decided to take a chance and 
vote for the resolution favoring an RVS, without in any 
way endorsing Hsiao’s published recommendations.” 
“Cognitive” v “procedural” was envisioned as one of 
many problems. To understand the forces at play in this 
important contest, I shall begin by identifying the oppos- 
ing parties and issues, and reminding ourselves of the 
forces that led to this study being undertaken. The US 

STEWART J. PETRIE, M.D., Attending Physician, Griffin Hospi- 
tal, Derby, CT. Dr. Petrie practices Obstetrics and Gynecology in 
Derby. He is a CSMS Delegate to the AMA. 

government and HCFA are the chief contenders in this 
effort; if there are limited dollars to be spent on medical 
care, then some system for appropriate allocation has to 
be developed. Opposite this powerful force, one recog- 
nizes organized medicine as the champion of the patient’s 
welfare and of the physician’s continued ability to prac- 
tice in a way best for patient care. Surely we understand 
that the system of diagnosis related groups (DRG)s 
would be much more unreasonable had the AMA not 
tried to work to make sense out of this unique way of 
determining Medicare payment. 

In an editorial from the Wall Street Journal entitled 
“Medicare’s Money Pit” the writer quoted Sen. Allen J. 
Ellender in 1965 as follows: “Let us not be so naive as to 
believe that the Medicare program will not be increased 
from year to year to the point that the government will 
have to impose more taxes on the little man or else take 
the necessary money out of the Treasury.” To under- 
stand the dilemma that Congress must face, it is worth- 
while to note not only the “over-promising” done initially 
in the Medicare program but also the budgetary con- 
straints that now are impacting on us. The Money Pit 
editorial goes on to state that “within 15 years Medicare 
outlays will equal those for defense or Social Security. 
Only seven years after that, Medicare spending will equal 
that for Social Security and defense combined. The 
money pit becomes a black hole that threatens to suck in 
the entire budget. Medicare taxes the young to care for 
the old, but it offers the old no incentive to think about, 
much less restrain, the cost of their care. The elderly we 
know hardly want to burden their grandchildren, yet 
Medicare’s socialist incentives are encouraging them to 
do just that.” 

Dr. Roper, of HCFA, seems much in favor of a 
capitation program (?decapitation). To make the issues 
even more difficult to define and manage is the fact of 
possible controversy between the so-called “cognitive” 
and the “procedural physicians.” Before this study was 
begun, and certainly at regular intervals since that time, 
we have been admonished from above to keep our fences 
well mended and not allow divisiveness among physi- 
cians to become the “divide and conquer” method of 
government authorities. To muddy the waters still fur- 

VOLUME 53, NO. 2 


ther, controversy also has sprung up between rural and 
urban areas. Geographic differentials in payment have 
been unfair in the past and attempts to remedy this have 
been considered at the same time with the matter of 
physician payment. 

I must begin by stating that those who have not taken 
the time to learn what transpired could conclude that 
there was some sort of “sell-out” to RBRVS. Later I shall 
review the nature of this heated and lengthy reference 
committee debate, but for now, simply state that the 
report A A of the Board of Trustees is labeled “The 
National Study of Resource-Based Relative Value Scales 
for Physician Services: Evaluation of Final Report of 
Phase I and Implementation Issues.” This is a long way 
from any carte blanche endorsement of the Hsiao study. 
In the nearly eight years that I have been a delegate to the 
AMA, I have seen many important issues debated at 
length and with great vigor. Excellent reports have come 
from the Board of Trustees and its councils regarding 
such matters as AIDS, nursing shortages, tort reform, 
and other legislative and scientific matters. This report, 
however, ranks high in importance; it runs to 43 pages 
and is an excellent study which was widely supported by 
the conclusion of our meeting. The need for unity and 
cohesiveness was strongly endorsed, even by those of our 
members who have the most to lose by it. Wide-based 
input into the AMA Board of Trustee study as well as the 
depth of perceptiveness of the shortcomings of the Hsiao 
report are clearly defined. As an indication of how far- 
reaching and important this report was held to be, I 
mention the following. At most reference committee 
meetings, there are usually fewer than six speakers lined 
up at the microphones; in this debate, the entire Sunday 
afternoon (and on into Monday as well), there were over 
160 speakers and debaters on this topic. Wisely the 
AMA staff decided to ask this reference committee to 
start its w ; ork on Sunday afternoon, thus allowing the 
entire house to participate. No physician felt that he had 
to be elsewhere at some other reference committee and 
possibly miss important input and discussion on this 
document. In the end, there was wide concensus and 
commendation to the AMA board for their work on this 

What are the short comings of the Hsiao report? How 
were the wounds healed in the matter of cognitive v 
procedure colleagues? What about geographic differenc- 
es for payments? Where do we go from here? I shall 
quote directly from Report AA of the Board of Trustees 
from time to time, but will mostly list my own reactions 
to these proceedings. 

At the 1988 Annual Meeting, the AMA House of 
Delegates adopted Board of Trustees Report 00. 
Report 00 described criteria for evaluation of the 
Harvard study of resource-based relative value 
scales (RBRVSs) for physician services and rec- 
ommended that a full evaluation of the study be 
conducted before any implementation decisions 

were made. Issues related to implementation of an 
RBRVS-based Medicare physician payment sys- 
tem were also reviewed in Report 00, and a policy 
recommendation supporting a transition period 
between the current Medicare physician payment 
system and any system involving payment sched- 
ules was adopted. Attention is also directed to the 
October 1988 issue of JAMA, since it was devoted 
exclusively to the Harvard study. The study began 
in December 1985 and a 2,000 page final report 
was submitted to HCFA in September 1988. Other 
alternatives to the RVRBS, even more unpalata- 
ble, would include such matters as DRGs, wide- 
spread capitation, Medicare PPOs, expenditure 
caps, and further constraints on Medicare’s current 
customary-fee and unreasonable system. Mount- 
ing budgetary pressures have placed the Adminis- 
tration and Congress in a situation where all of the 
above have been considered. It is felt that these 
proposals undermine the independence of the med- 
ical profession and pose serious threats to the clini- 
cal decision making of physicians for their Medi- 
care patients. In contrast, Association policy argues 
that an indemnity payment schedule based on an 
appropriate RVS could be the basis for a more 
acceptable Medicare physician payment system 
that would preserve fee-for-service medicine, while 
eliminating much of the complexity that has pro- 
gressively plagued CPR. 

This Board of Trustee report makes 19 recommenda- 
tions related to this study; I shall list some of the more 
critical ones: 

1. Recommendations in regard to relative value scale. 
That the AMA reaffirm its current policy in support of 
adoption of a fair and equitable Medicare indemnity 
payment schedule under which physicians would deter- 
mine their own fees and Medicare would establish its 
payments for physician services using appropriate RVS 
factors and conversion factors. 

2. That the AMA adopt the position that the current 
Harvard RBRVS study and data, when sufficiently ex- 
panded, corrected, and refined, would provide an accept- 
able basis for a Medicare indemnity payment system. 
(Much testimony was brought out that this study is 
actually incomplete in the case of many important spe- 
cialties and thus carte blanche endorsement cannot be 
given.) Ongoing refinement and completion of the study 
is an important factor in its acceptance. This would 
include appropriate action to address concerns for indi- 
vidual specialties as well as a mechanism to ensure that 
additional concerns not be put aside but be brought to 
the attention of the appropriate parties with their proper 
validation as conducted by the AMA. 

3. “Balance billing” is a nonnegotiable item since the 
AMA feels that this is important to ensure physician and 
patient rights to deal with each other in a traditional 
fashion. To the credit of the doctors present, it was also 



heavily endorsed that the AM A support state and county 
medical society initiated voluntary assignment programs 
for low income, Medicare beneficiaries. (Connecticut 
physicians have been in the forefront with our courtesy 
card program.) In the meantime, recommendations fur- 
ther affirmed the AMA’s opposition to the maximum 
allowable charge (MAAC) limits, as well as the impor- 
tance of promoting and enhancing physician discussion 
of fees with patients as an explicit objective of Medicare 
indemnity payments. 

It seemed important to me that there be a balanced 
billing policy along with the matter of transition to min- 
imize disruption of patient-physician relationships dur- 
ing this period when corrections are made as needed. 
Eliminating geographic differentials are being addressed 
as well as consideration of access problems in specific 
geographic areas. The AM A should strongly oppose any 
attempt to use the implementation or subsequent use of 
any new Medicare payment system to freeze or cut Med- 
icare expenditures for physician services in order to pro- 
duce federal budget savings. There is an old saying: “fool 
me once, shame on you — fool me twice, shame on me.” 
We have all seen it come to pass that in our zeal to help 
some new system get under way, we have accepted a 
slightly substandard fee only to find out that there was 
little possibility of ever changing the fee. The Board of 
Trustees addresses the updating of the fee schedule as 
follows: That whatever process is selected to update the 
RVS and conversion factor, only the AM A has the 
resources, experience, and umbrella structure necessary 
to represent the collective interests of medicine, and that 
it would seek to do so with appropriate mechanisms for 
full participation from all of organized medicine, espe- 
cially taking advantage of the unique contributions of 
national medical specialty societies. 

The last several pages of the report deal with an over- 
view of the Harvard RBRVS study. In case you have 
wondered what the RB before RVS really amounts to, it 
concerns many matters other than physician charges 
(which have been the basis of previous relative value 
scales). The Harvard report argues that resource costs 
are more appropriate bases for RVS. Current AM A 
policy supports this view. To emphasize the ongoing 
nature of this Harvard study (rather than something 
which has been finalized and to be implemented as is), is 
the fact that Congress has mandated that initially 15 
specialties be included. Harvard has been funded by 
HFCA to extend its study to these additional specialties 
i in a second phase to begin this winter. 

There are those who might wonder whether the per- 
sons in charge of validating this study were representa- 
tive of medicine as a whole. For this reason, there were 14 
technical consulting groups (TCGs) brought together, 
comprising representatives of 20 specialties, the Ameri- 
; can Board of Medical Specialties, six subspecialties of 
internal medicine, and oral-maxillofacial surgery. The 
weakest portion of the study is the lack of external 

validity checks, ie, comparison of the survey results with 
other measures of resource costs. In this regard, the 
comments of the TCG physicians, who provided the 
strongest check on how well the survey results reflected 
clinical practice, do not receive sufficient attention in the 
study’s final report. More detailed discussion of the 
TCG’s reactions to the survey findings in the Harvard 
report might have provided more evidence for the valid- 
ity of this measure of intraservice work. 

In addition, it is clear that the study would have 
benefited from more timely provision of information to 
TCG physicians, as well as a greater responsiveness to 
some of their expressed concerns. AMA staff will work 
to ensure that use of the TCGs during the second phase 
of the study is improved to respond to these deficiencies. 

The matter of balance billing has been given great 
scrutiny and analysis. The AMA has long opposed man- 
datory assignment and has supported physicians’ right to 
establish their own fees. In addition, the AMA has had a 
number of concerns about the Medicare Participating 
Physicians Program and has sought repeal of it and the 
MAAC limits established in the current system. Although 
the Association was not successful in obtaining a court 
finding invalidating MAACs, the 14 October 1988 writ- 
ten opinion of the United States Court of Appeals, Fifth 
District, recognized the MAACs as being “ridiculously” 
complex, and as deterring top students from applying to 
medical school. The Association also urges physicians to 
consider their patients’ ability to pay and to accept 
assignment or charge a reduced fee or no fee in instances 
of patient financial need. This was a “nonnegotiable” 
item because of the AMA’s championing this position. 
The other equally important point is liberal acceptance 
of this payment as payment in full when there is any 
question of the patient’s ability to pay. Attention is 
drawn to the editorial in the October 1988 issue of 
JAMA by J.S. Todd, M.D., which states: 

No one should consider an RBRVS, which itself 
has no monetary meaning, as fulfilling the criteria 
necessary for a fixed fee schedule. The RBRVS, 
like any RVS, is based on averages .... An RBRVS- 
based system cannot recognize differences between 
physicians in patient mix, quality, or practice costs. 
Nor can it account for local market conditions that 
affect access to care.... A properly working 
RBRVS-based fee schedule will require the flexi- 
bility that comes with the ability to balance bill .... 
Rigid price regulations inevitably produce distor- 
tions that harm consumers and producers alike. 

The final report of the Harvard RBRVS study 
indicated that if the RBRVS is to be used as a basis 
for a fee schedule, geographic variation in costs 
among physicians should be reflected in the con- 
version factor. 

If you have waded through this article, thus far, and 
wish to take heart in some important outcomes of this 

VOLUME 53, NO. 2 


matter, address your attention to some conclusions and 

Continuing high rates of growth in Medicare ex- 
penditures for physicians services, and mounting 
pressure to reduce the federal budget, have made 
Medicare physician payment reform a focal point 
on Congress’ agenda. Congressional and Adminis- 
tration attention to physician payment has to date 
produced fee freezes, MAACs, inherent reason- 
ableness cuts, and proposals for widespread capi- 
tation, DRGs, Medicare PPOs, and expenditure 
caps. With the implementation of MAACs and 
inherent reasonableness cuts, the CPR system be- 
came moribund. The alternatives to CPR offered 
to date pose serious threats to the ability of physi- 
cians to continue providing high quality, accessible 
health care for their Medicare patients. 

Medicine must have its own Medicare payment 
proposal. An RBRVS-based indemnity payment 
system has been viewed as a credible alternative 
and has already served the profession well in re- 
straining some of the enthusiasm for more disrup- 
tive proposals. That the AMA adopted the posi- 
tion that the current Harvard RBRVS study and 
data, when sufficiently expanded, corrected, and 
refined, would provide an acceptable basis for a 
Medicare indemnity payment system.” 

The concept of balance billing seems only fair to the 
AMA and its member physicians, but will possibly be 
unpopular with Congress in their zeal to remain popular 
with their constituencies. We must offset our desire for 
balance billing by being extremely responsive to the 
medical needs of patients in low income brackets. Keep 
in mind that we have not accepted the Hsiao study as 
such but have accepted the AMA report the highlights of 
which are listed above. The fact is that there will be a 
gradual transition to such a program, that balance billing 
is an important part of it, that regular updating is to 
occur with it, and, most importantly, that it will not be a 
basis for payment until some of these wrinkles have been 
worked out. Lord Cardigan may have said to his light 
brigade “OK folks, let’s take a little stroll down the valley 
to Balaklava.” If we think of the government as Lord 

Cardigan, then I believe the perceptiveness of the physi- 
cians studying this program will keep us from being 
deluded as to just what is happening. 


1 . If one understands and believes what has been noted 
above, then the conclusion is that some new system must 
be devised for payment of medical services. 

2. While the Board of Trustees report in evaluation and 
recommendations of the RBRVS study was ultimately 
acceptable to the delegates, the Hsiao study was not. (It is 
incomplete and flawed in many ways and is to be 
reviewed further and ruled upon.) 

3. The problems of rural v urban differential will be 

4. A gradual phasing in of this entire program to avoid 
disruptions is mandatory. 

5. The acceptance of a “balance billing concept” will be 
necessary and only fair to allow full access to medical 
care. There seems to be some “inherent reasonableness” 
to the fact that the well-to-do senior citizen would expect 
to be balance billed, and on the other hand, the indigent 
elderly person would receive excellent medical care, as 
proposed by our present “courtesy card program.” 

6. Ongoing surveillance by medical authorities will be 
needed to avoid the subversion that so often happens to 
well-intentioned programs. 

Dr. Russell Roth (past president of the AMA) has 
helped lighten the atmosphere among many of our 
stormy debates over the years. He has done this by well 
designed and appropriate limerics. The one that he con- 
cocted for this particular problem goes as follows: 

“It is true that our health depends, 

On our congressional friends, 

To grant this convention, this brief intervention, 
Remember Jesus saves and Congress spends.” 

It can thus be seen from all of the above, that this 
“shoot out” wound up not being a deadly and divisive 
affair. A note of harmony allowed all of the factions to 
“spike their guns.” Great credit for this belongs to not 
only the excellent report A A of our Board of Trustees 
but also to the long range perceptiveness of our member- 
ship who realized the necessity for this approach. 



View from the Hill 


T WO months ago, this column offered a general 
introduction to the most recent of a series of highly 
significant reports issued by the Institute of Medicine 
(IOM) on various issues affecting medical practice and 
the health of the American people. Titled “The Future of 
Public Health,” this report deserves further attention. 

The IOM’s Committee for the Study of Public Health 
found, somewhat ominously, that public health vigilance 
has typically and generally slackened. It suggested that 
the central need is for “public concern and concerted 
action.” However, despite avid public interest and deep 
concern about the AIDS problem and the mounting 
social crisis of drug dependency, the IOM study revealed 
a lingering public reluctance to accept the reality that 
health, in all its manifestations, is both an individual and 
a social responsibility. Of course, to participate in health- 
promoting activities, the public must be informed of the 
needs as well as the opportunities to support the protec- 
tive services provided by the community. 

The committee found wide variances among and 
within the states in the standards of performance and the 
degree of popular support for public health agencies and 
their programs. Many localities have no health depart- 
ment at all. Some states do not include environmental 
problems, prenatal care or mental health services in their 
public health agendas. Some combine health and social 
services without much depth in either area. 

One recalls the agitation, two decades ago, for a 
National Department of Health, separate from welfare, 
education or human services. The designation of Otis 
Bowen, M.D., a family physician, as the first physician 
secretary of the Department of Health and Human Serv- 
ices has seemingly demonstrated that human services 
and health services are really interdependent — a concept 
that should help restore the public health mission to 
appropriate status in our popular value system. 

Besides a growing failure of interaction between the 
clinical profession and public health professionals, the 
latter suffer a sort of vocational insecurity more typical 
of the political than the professional life. The committee 
reports that the average tenure in office for a state health 
officer is now two years. There is also a “growing percep- 
tion of health as big business,” which is surely a mistaken 

JAMES E. BRYAN, Washington Correspondent, American Fam- 
ily Physician. 

Reprinted from American Family Physician. Copyright 1989 by 
American Academy of Family Physicians. 

perception as applied to professional public health ad- 
ministration and practice. This “has led to attempts to 
take public health out of the hands of the doctors” by 
subordinating the health officer to the nonmedical admin- 

The public health officers who would cultivate public 
knowledge and support for their efforts are hindered by 
the circumstance that crises, not successes, are the stuff of 
news in public health endeavors. Beyond that, the com- 
mittee found that public health officers often ignore or 
discount the political realities of democracy or its rele- 
vance to their work. 

Public support for research in public health areas and 
availability of technical expertise in the field suffer from 
the dearth of popular interest. Furthermore, low salaries, 
an inferior public image and declining professional pres- 
tige seriously hamper recruitment of competent leaders 
in the field. 

The committee identifies the “core functions” of public 
health agencies as (1) assessment of health status, needs 
and problems; (2) leadership or assistance in developing 
policy, and (3) assurance that services and protections 
are financed, in place and available. The basic functions 
and responsibilities of the federal health authorities are 
summarized as research, information exchange, setting 
national objectives, providing technical help, subsidizing 
necessary services in the states, and assuring action and 
service to meet national health problems. The committee 
reminds us, however, that our government spends more 
at all levels on personal health and medical services than 
on population-based health functions, thereby tending 
to minimize the preventive function of medicine. 

In a not uncommon sense, public health practice in the 
United States is a victim of its own successes. The health 
problems that public health practice was challenged to 
attack — safe water, protection against epidemic diseases, 
infant mortality and the like — have yielded as problems, 
but they persist to the extent they do because of a lack of 
vigilance or a failure to apply the meager funds needed to 
carry on. 

An active, well-supported public health service is as 
essential to the welfare of our society as a competent, 
conscientious physician is crucial to an individual patient. 
We should add a public health effort to our roster of 
critical public interest deficits. 

VOLUME 53, NO. 2 





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Family Practice 

The report, “The Future of Family Practice,” in this 
issue of Connecticut Medicine identifies some interesting 
facts regarding the specialty of family practice. Family 
physicians have the largest number of patient visits of 
any specialty, and family practice is the specialty in 
greatest demand in today’s medical marketplace. Yet 
family practice has not gained status in the academic 
community. Family practice has certainly gained strength 
in medical schools since its inception as a specialty in 
1969; however, as stated in the report, its status is still 
lacking. In the eye of the general public, though, the 
! status and the need for family physicians has grown. This 
is evidenced by the demand for family physicians and the 
number of patient visits to family physicians. Why is the 
academic community unwilling to recognize and support 
training to satisfy this area of need in medicine today? 
The report gives a number of reasons for this lack of 
status: competition with other primary care specialties, 
lack of the traditional depth of other specialties, lack of a 
research and publication base, and lack of role models 
for medical students. 

Competition does exist between family practice and 
other primary care specialties. The other specialties con- 
tinue to produce physicians in their specialties, and by 
and large these specialists remain busy. Also, competi- 
tion should be beneficial, with each specialty working to 
provide better medical care for our patient populations, 
rather than bickering with each other. Therefore, I do 
not see competition as a legitimate reason for lack of 

The breadth of family practice does cause concern 
among those specialists who have trained in depth. 
When this is a true concern, it may be justified; when it 
represents elitism, it is clearly not justified. The academic 
community needs to examine its basis for not granting 
status to family practice to determine whether it is elitism 
or a true concern over the breadth of training for family 

To date, family practice has not emphasized research 
and publication as much as the other specialties, although 
research is being done and there are excellent journals of 
family practice. The slow development of research has 
been the appropriate approach since, as a new specialty, 
family practice needed to develop a strong clinical base. 
Without such a base, research could not be performed 
and accomplish meaningful results. Family practice is a 
clinical specialty and, therefore, its research should be 
primarily in clinical fields. As family practice depart- 
ments become stronger and family practice residencies 
more stable, research has begun to develop in the spe- 
cialty. As noted, funding for research in family practice is 

Editorials are expressions of personal opinion and do not necessarily 
reflect the policies of CSMS. 

Connecticut Medicine does not hold itself responsible for statements 
made by any contributor. 

a significant problem and the specialty will need to 
develop methods for funding meaningful research. 

Although research is important, I believe the academic 
community must reevaluate clinical teaching and recog- 
nize it as being just as important. For instance, many of 
us involved in residency training programs identify two 
major deficiencies in American trained medical students 
entering our residency programs. One deficiency is the 
inability of entering residents to take an adequate history 
and perform a skillful physical examination and inter- 
pret their findings. The other is the lack of clinical prob- 
lem solving abilities in an ambulatory care setting. These 
are basic to good medical practice and are being ne- 
glected in medical school clinical education. Clinical 
medicine should be valued by medical schools on a par 
with research if we are to continue to maintain an excel- 
lent medical care system in this country. Family practice 
is a clinical specialty which could, and should, be a leader 
in teaching and demonstrating good clinical medicine. 

The need for role models does exist in the academic 
setting and will continue to exist until the academic 
community recognizes the role and value of the family 
physician. Role models are available in the community, 
and these physicians must be utilized by the medical 
schools until they develop strong departments. 

Family practice must continue to address the prob- 
lems of funding for residency programs. Federal and 
state funds have been available to date and may be 
available in the future. However, other sources of fund- 
ing are being investigated by family practice. 

Reimbursement has been a problem for family prac- 
tice. Nevertheless, the majority of physicians in practice 
are satisfied with their total practice situation. The 
RBRVS represents a hope for improving the financial 
outlook for family physicians. 

Family practice as a specialty has grown in numbers 
and status since its inception. The specialty is committed 
to providing excellent medical care to the communities 
of this country, both rural and urban. The proliferation 
of specialties in depth has led to a lack of available and 
appropriate care for large segments of our population. 
Family practice has recognized this lack of care and has 
endeavored to develop specialty training in breadth to fill 
the gap. The medical community has a responsibility to 
all segments of our population, not only those in tertiary 
care hospitals. We must recognize this responsibility and 
work together to train physicians to provide this care. 
Cooperation is needed at all levels of care, from training 
medical students to relationships between physicians in 
practice. By developing a cooperative attitude, we can 
not only have the best technology and tertiary care medi- 
cine, but also supply excellent medical care to all seg- 
ments of our population. 

Dewees H. Brown, M.D. 

Middletown, CT 

VOLUME 53, NO. 2 


Guest Editorial 

Informed Consent and 
Common Sense 

In my role as an attorney for hospitals, other health 
care facilities and associations, and physicians, I have 
advised clients and written extensively on the doctrine of 
informed consent for a number of years. Recently, I have 
thought a great deal about the philosophical aspects of 
the doctrine and have concluded that it is in need of 
surgery. As it has developed and been formed by the 
courts, it just cannot be squared with reality in certain 
important areas. In addition, I believe that the doctrine 
seems to be abused in that it sometimes appears to be 
used as a device to provide recovery to a patient who has 
experienced a bad result when negligence cannot be 
established, even though there has been an attempt to 
inform the patient which, upon analysis after the fact, 
was not perfect. 

The courts have developed the doctrine of informed 
consent with the implicit assumption that it is possible 
fully to inform a patient about the advisability and the 
risks and benefits of the procedure in question. This 
assumption often is at variance with the facts. 

Not infrequently, for example, there is clear and some- 
times heated disagreement among the “experts” as to 
whether or not procedures should be performed. 

In addition, the medical literature often is conflicting if 
not confusing in regard to the frequency of a risk occur- 
ring. In the use of low osmolality contrast media, for 
example, the literature offers research studies showing 
the risk of death ranging from one chance in 10,000 or so 
to one chance in many hundreds of thousands. Some of 
the studies showing extremely low risks have been ser- 
iously questioned by the leading expert on the use of such 
media as indicated in our recent article on the subject 
{Conn Med 1988;52:87-91). 

Does it really make sense to require the physician to 
inform the patient, for example, that three articles sup- 
port performing the procedure while two do not; or that 
the magnitude of the risk depends upon which study you 
want to accept? Obviously, even a Connecticut physi- 
cian, who is required to meet a hypothetical national 
standard of care, cannot be expected to analyze the 
research methods and statistical controls used in each 
study and then present his own analysis to the patient, 
nor can he be expected to hire his own experts to attempt 
to understand and resolve the conflicts contained in the 



In addition, does it make any sense to require that 
courses of treatment that clearly are inadvisable from a 
prevailing point of view nevertheless have to be disclosed 
and explained? 

Or, does it make sense to provide a large recovery 
when there has been no negligence and there was an 
attempt to inform the patient and obtain consent, even 
though it was not perfect when viewed with hindsight? 

In my view, we should consider adopting by statute a 
consent requirement which provides that the physician is 
not required: 

(1) to resolve or sketch out in any detail all disagreements 
as to the advisability of the procedure or disagreements 
as to the magnitude of the risks involved; 

(2) to inform the patient about alternatives which gener- 
ally are not considered advisable; nor 

(3) to inform the patient about risks which are not gener- 
ally considered to be significant or risks generally thought 
to occur rarely. 

Finally, and most importantly, if there has not been 
any negligence there only should be recovery under the 
doctrine of informed consent if there has been a complete 
or serious failure to inform the patient about major 
known risks. The doctrine should not be a device which 
can be used when negligence cannot be established and 
there was a reasonable — albeit imperfect — effort to in- 
form the patient. Recovery under a claim of failure to 
obtain informed consent should only be permitted if: 

(1) it is established by expert testimony that the failure to 
inform was very serious in light of the failure to disclose 
major risks which generally are known and routinely are 
disclosed; and 

(2) the trier of fact (judge or jury) also concludes that if 
there had been full consent a reasonable patient might 
have decided to forego the procedure. 

(3) In addition, if it is determined under (1) and (2) above 
that there should be a recovery by the patient, in calculat- 
ing any damages the court must consider, in mitigation 
of such damages, the patient’s probable life expectancy, 
or probable conditon without having had the procedure, 
as developed by expert testimony. 

J. Michael Eisner, Ph.D., J.D. 

Attorney Eisner is a partner with Wiggin & Dana, New Haven and 
Hartford, CT. 


The President’s Page 

Reform From Within 

It was most heartening to me in early January to read a newspaper 
account of the Connecticut Supreme Court ruling that lawyers 
may no longer tell juries how much money their clients should 
receive in damages for pain and suffering. The amount of such 
proposed payments has always been based on intangible and even 
capricious estimates resulting in inequitable decisions, in my view, 
with greatly variable awards for the same or similar outcomes of 
accidents, malpractice or other liability situations. 

I believe this ruling partially corrects the problem of noneco- 
nomic damages. The Supreme Court Justices have apparently 
changed their minds about the fairness of allowing plaintiffs’ 
attorneys to attempt to influence juries directly on the size of 
awards. It is gratifying to see that our legal system still has the ability to adjust from within, thus 
avoiding the sensationalism and adversarial reaction when such reforms are attempted by 
legislative mandate. 

This new ruling was arrived at after the review of two cases, one a malpractice case with an 
exorbitant award, and the second an accident case where a jury awarded the $30,000 that the 
plaintiffs attorney recommended as compensation for 46 days out of work and continued 
complaints of neck and arm pain. As the Supreme Court stated, “when a jury arrives at an award 
of damages, if any, they do so as the neutral and impartial triers of fact. Suggestions by a 
plaintiffs counsel, on the other hand, are statements made in the course of the zealous 
representation of a client’s cause, and therefore are completely self-serving.” 

More specifically, in one of the cases Judge David M. Shea stated that “the practice of 
mentioning the sum to be awarded to the plaintiff for pain and suffering constitutes an 
unwarranted intrusion into the domain of jurors,” and that stating the amount claimed 
“encourages exorbitant demands by counsel.” 

As I stated previously, this is a laudable but only a partial correction of the problem. It would 
not seem to be such a large step from there to a more rational system of awarding noneconomic 
damages which are comparable between cases of similar nature, and thus more predictable. By 
definition, non-economic damages are difficult for jurors and others to assess fairly in economic 

Several alternatives are already available to accomplish this change, and I would hope that 
the courts would consider such further reform. As physicians whose significant medical liability 
insurance premiums pay for the bulk of the medical malpractice portion of the awards system, I 
believe we have a significant interest in this reform, and hope that this concept can be brought to 

If it doesn’t happen from within, then I believe it would be worthwhile to promote it 
legislatively, not only for us, but for other individual and corporate defendants, such as other 
professionals, hospitals, stores, schools, and municipalities. 

Norman A. Zlotsky, M.D. 



With the Council’s approval, we are urging all physicians to continue honoring the old CSMS 
Medical Courtesy Cards beyond the deadline of 12-31-88, and to advise their senior patients 
who have not yet applied for a replacement “ConnMAP” card to contact the Department of 
Aging immediately at 1-800-634-8852. It has come to our attention that many seniors have not 
yet had their CSMS cards replaced by the State of Connecticut Medical Assignment Program 
(Conn MAP). 

VOLUME 53, NO. 2 



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Reflections on Medicine 

Too Much Science? 


You may recall that in the opening paragraph of his 
essay, “The Care of the Patient,” Francis Peabody wrote. 

The most common criticism made at present by 
older practitioners is that young graduates have 
been taught a great deal about the mechanism of 
disease, but very little about the practice of medi- 
cine — or, to put it more bluntly, they are too 
“scientific” and do not know how to take care of 
patients. 1 

Last year, 60 years later, Samual Thier spoke of the 
criticism aimed at house officers and medical students 
that they were inhumane and excessively scientific, and 
then added, “When you stop hearing that new graduates 
are too scientific, it means the field is not advancing and 
training them better than the old... .” 2 

Both Peabody and Thier were trying to say that medi- 
cine should not be either all science or all humanism 
(although Peabody did not use that term), nor, I believe, 
were they implying that it was a little of each. In 1927 
scientific medicine was still a novelty for many doctors 
over 45; there were practitioners in their 50s and 60s 
whose medical school years had been at the threshold of 
modern scientific medicine and who might have had little 
instruction in bacteriology or biochemistry. They would 
have resented those coming out of Harvard, Yale, Hop- 
kins, or Michigan, and would not have understood much 
that they were talking about. They would have feared 
competition from the newcomers who knew so much 
and whose knowledge seemed so marvelous to their 
patients. It was a time when faith in scientific progress 
was running high, and the modern doctor in the eyes of 
many was the epitome of the scientific man. Peabody 
pointed to the “amazing progress of science in its relation 
to medicine during the last thirty years,” but went on to 
give the “practitioner of the older generation” his due: 
there was much in his art to teach the new crowd. 

Thier, I believe, referred to criticism coming from 
without, the questioning of biomedical science and tech- 
nology that has stubbornly persisted, especially among 

ROBERT U. MASSEY, M.D., Professor, Division of Humanistic 
Studies in Medicine, Department of Community Medicine and Health 
Care, University of Connecticut School of Medicine, Farmington, CT. 

those who came of age in the ’60s, as well as among some 
social scientists and public health people whose concern 
is more with denominators than with numerators, with 
populations rather than individuals. 

Medical schools have tried to resolve this problem by 
bringing in the humanities, and by urging undergradu- 
ates not to neglect history, literature, languages, and 
philosophy during their four years of college. All of this 
is good for education and adds to the quality of the 
physician’s life, but there are no data showing that hum- 
anists are more humane than scientists or better practi- 
tioners of the art. 

Peabody and Thier came to similar conclusions: the 
merging of science and art occurs in the clinic or at the 
bedside or not at all. “The treatment of a disease may be 
entirely impersonal; the care of a patient must be com- 
pletely personal,” wrote Peabody, and he might have 
added that the care of patients is no less important 
because there is “nothing the matter with them.” Indeed 
it was these patients with their headaches and backaches, 
belly pains and insomnia, depression and anxieties that 
always baffled young physicians from academic teaching 
hospitals, whether in 1989 or 1927. 

Dismiss them with a “There’s really nothing the matter 
with you,” or knock them low with diazepam, and they 
will soon dismiss the whole profession and seek help 
from some “alternative” practitioner. When science fails, 
they, and even we, may turn to magic. But the skillful 
physician has something more than science, never to use 
in its place, yet not magic either, and that is his under- 
standing of what Osier called “this deliciously credulous 
old human nature in which we work.” These things are 
taught and learned at the bedside and in the clinics, and 
for those with eyes to see them, in novels, plays, and 
poetry, but rarely in behavioral science courses. They are 
taught mostly by example and learned only by expe- 


1. Peabody, FW: The care of the patient. JAMA 1927; 88:887-82. 

2. Thier, SO: The range of significant issues in medicine, in The 
Medical Profession: Enduring and New Challenges, Medical Edu- 
cation Group, AM A, 1987, pp. 23-30. 

VOLUME 53, NO. 2 


• Epitomes of Progress — Each month this section highlights the major advances 
in a different specialty with 15 or 20 brief epitomes by experts in the field. 

• Clinical Investigation — Five major clinical research societies coordinate 
important new research findings, emphasizing clinical value. 

• Socioeconomics — WJM is often the first to predict, examine and evaluate socio- 
economic changes, trends. 

• Yearly Special Issue — Each December’s issue is devoted to a topic vital to 
physicians : clinical nutrition ( 1979 ) , cost of care ( 1980 ) , geriatrics ( 1981 ) , 
occupational/ environmental ( 1982 ) , cross-cultural medicine ( 1983 ) , personal 
health maintenance ( 1984 ) , high-tech medicine ( 1985 ) , medical 
informatics ( 1986 ) . 


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Winter Reading: The Past and Future of Health Law 


; T^HYSICIANS interested in understanding law and 
I IT its increasing role in regulating the health care pro- 
cess are confronted with an impressive, if not imposing, 
i array of books, journals, and articles. For most of these 
j readers, however, it is not always clear where to begin or 
how to keep up to date. Complicating this search for 
understanding is not only the difficulty of keeping pace 
with any rapidly changing field, but also the difficulty of 
acquiring the breadth necessary to be comfortable with 
the wide range of topics and perspectives embraced 
under the heading of health law. Legal and ethical issues 
within the doctor-patient relationship, such as those 
raised by the McConnell case, are one aspect of health 
law involving the rights, duties, and goals of the various 
parties. Larger policy questions such as how best to deal 
with cost and quality issues are a second aspect involving 
legal regulation of the professional and commercial 
dimensions of the health care process. Each represents a 
different perspective and each requires a different ap- 
proach. Two recent health law volumes, each by a differ- 
j ent health law scholar and each emphasizing a different 
aspect of health law, provide a good place to start or to 
continue one’s self-education in health law. One book 
emphasizes the major cases and issues dealing with 
patient rights during the past fifteen years. The other 
emphasizes the regulatory aspects of health care as a 
business. Together, the two volumes provide a useful 
starting point for the interested reader. This month’s 
column will focus on the first of these books. 

George J. Annas is the Utley Professor of Health Law 
at Boston University School of Medicine and Chief of 
the Health Law Section at Boston University School of 
Public Health. In Judging Medicine, 1 he has collected 61 
of his articles written during the past 15 years. Most of 
the articles originally appeared in the leading journal for 
those interested in health law and medical ethics, The 

JOSEPH M. HEALEY, J.D., Associate Professor, Department of 
Community Medicine and Health Care, University of Connecticut 
School of Medicine, Farmington, CT. 

Hastings Center Report. The articles have been organ- 
ized by theme into nine sections: patient rights; concep- 
tion; pregnancy and birth; reproductive liberty; medical 
practice; the mentally retarded and mentally ill patient; 
death, dying, and refusing medical treatment; govern- 
ment regulation; and transplants and implants. The indi- 
vidual articles are usually four to six-page discussions of 
what are now recognized as the leading cases and con- 
troversies during the past 15 years including: abortion, 
surrogate parenting, maternal-fetal conflict, decisions in 
the neonatal intensive care unit, malpractice, and deci- 
sions about withholding and withdrawing support at the 
end of life. The articles reflect the development of health 
law during this period of great activity when cases involv- 
ing ordinary people, such as Karen Quinlan, Baby Doe, 
and Elizabeth Bouvia, attracted worldwide attention. 
This has been a period during which many claims by 
patients have been recognized as legally enforceable 
rights by courts and legislatures. Emphasizing his long- 
standing interest in analyzing the rights and duties of 
patients and health practitioners, Professor Annas pro- 
vides a look back at how health law principles have 
developed in and through these cases and a look forward 
at the unfinished agenda which remains. Professor Annas 
is a perceptive analyst and commentator. He provides a 
strong and articulate voice for the patient rights perspec- 
tive and he challenges health professionals to reexamine 
the goals and the content of their relationships with their 
patients in light of the evolving recognition of the legal 
rights of patients. His volume is a stimulating introduc- 
tion to this aspect of health law. 

Next month’s column will discuss Clark Havighurst’ s 
new volume, Health Care Law and Policy: Readings, 
Notes, and Questions. 2 


1. Annas GJ: Judging Medicine. Clifton, New Jersey, Humana 
Press, 1988. 

2. Havighurst CC: Health Care Law and Policy: Readings, Notes, 
and Questions. Westbury, New York, The Foundation Press, Inc., 

VOLUME 53, NO. 2 



Life, Death, and Public Policy 

By Robert H. Blank. 177 pp. DeKalb, Northern Illinois 
University Press. 1988. $8.50 (paper); $22.50 (cloth). 

In presenting an “overview of the hard life-and-death 
decisions” that we as a society face as the result of recent 
rapid advances in biomedical technology, Blank con- 
sisely describes both the technological developments 
themselves and the evolving policy concerns that they 
engender. He touches on such wide-ranging subjects as 
eugenics, sex selection, genetic counseling and screening, 
abortion, sterilization, prenatal diagnosis, artificial in- 
semination, in vitro fertilization, fetal research, psycho- 
surgery, electrical brain stimulation, drug therapy, and 
organ transplants. In covering so many complex topics 
in so little space, Blank is admittedly not attempting to 
provide an “in-depth analysis of any single biomedical 
technology.” He does, however, accomplish his stated 
goal of focusing on “the broader social-policy dimen- 
sions raised by [the] biomedical revolution in which even 
the basic definitions of life and death are challenged.” 

For Blank “all biomedical technologies focus funda- 
mentally on the question of the extent to which we ought 
to intervene directly in the human condition.” He has 
divided this book into six chapters with most technolo- 
gies grouped according to their impact at a particular 
stage along the life cycle. Chapter one sets up the policy 
context and describes the “broad assortment of biomedi- 
cal technologies” that have recently surfaced. Blank 
warns that “only major alterations in the U.S. health care 
system can avert a crisis of immense proportions in the 
coming decades.” He asserts that in the United States the 
“distribution of medical resources is heavily skewed 
toward a very small proportion of the population.” Two 
factors contributing to this are the emphasis that Ameri- 
cans have traditionally placed on the concept of individ- 
ual rights and our societal “obsession with [the] prolong- 
ation of life.” Blank sees increased governmental involve- 
ment in setting policy as unavoidable. His insights, 
however, would be more useful if the reader were pro- 
vided with information as to his own professional back- 
ground and perspective. Nowhere, at least in the paper- 
back edition, is it revealed that the author is a professor 
of political science at Northern Illinois University and, 
because of the breadth of technical, legal, social, and 
ethical information conveyed, this omission as to his own 
frame of reference, is somewhat distracting. 

Chapters two and three are perhaps the book’s richest. 
Chapter two deals with “Human Genetic and Repro- 
ductive Intervention” and chapter three with “Prenatal 
Intervention.” Here Blank demonstrates the effect of 
biomedical innovations on fundamental societal values. 
He points out, for example, that although some advan- 

ces “promise to alleviate the individual and social costs of 
genetic disease and give us more control over the destiny 
of future generations... widespread use of these technol- 
ogies expands considerably our ability to label and 
categorize individuals according to precise genetic fac- 
tors — thus effectively minimizing the human aspects of 
humanhood.” Although he can only cover each topic 
superficially, he rasies important questions and offers 
diverse insights from many well-respected sources. Blank 
examines the policy implications relating to reproductive 
technologies in a context that includes questions about 
reproductive rights as well as potential reproductive 

Chapter four, entitled “Biomedical Issues Within the 
Life Cycle,” explores questions surrounding the neonatal 
ICU, organ transplantation, behavior modification or 
control via medical intervention with drug therapy and 
psychosurgery, and human experimentation. In addition 
to highlighting policy issues, this chapter is valuable for 
its compilation of interesting statistics concerning neona- 
tal illness and mortality rates and for data pertaining to 
transplantation procedures in the United States. 

In chapter five, “Death Related Issues in Biomedi- 
cine.” the focus is primarily on classification and distinc- 
tions pertaining to euthanasia. Some recent court cases 
are outlined and a somewhat cursory reference is made 
to Alzheimer’s Disease as an illness that will, according 
to Blank, have increasing policy ramifications. 

The final chapter, “Policy Decisions in Biomedicine: 
Making Hard Choices,” examines questions of alloca- 
tion. Blank asserts the “even more critical than the 
general public’s support for resource allocation is the 
cooperation of the health-care profession.” He goes on to 
say that “physicians are particularly key decision makers 
on the demand side of medicine, since they serve as 
gatekeepers for access to treatment regimens, technolo- 
gies, and drugs.” Although he presents arguments for 
and against assigning the physician to this role, Blank 
writes that “despite its hesitency, the medical profession 
increasingly will find itself in the difficult position of 
responding to government initiatives and, eventually, to 
public pressures to make difficult allocation and ration- 
ing decisions.” 

Life, Death, and Public Policy provides a well-re- 
searched overview in which Blank has compiled many 
different views and perspectives. This volume, as stated 
in the preface, serves to introduce a new NIU Press series 
entitled, Studies in Biomedical Policy. In addition, the 
bibliography provides a wealth of information for those 
who would like to continue with more extensive study 
into specific subject areas. 

Nancy R. Williams, J.D., LL.M. 

Farmington, CT 



Letter to the Editor 

Letters to the Editor are considered for publication (subject to 
editing and abridgment), provided that they are submitted in duplicate, 
signed by all authors, typewritten in double spacing, and do not exceed 
iy 2 pages of text (excluding references). They should not duplicate 
similar material being submitted or published elsewhere. Letters refer- 
ring to a recent Journal article should be received within six weeks of 
the article’s publication. 


To the Editor: Ms Kendrick’s article in the December 
issue of the Journal must surely affect anyone who reads 
it. Its recital of repeated surgery, repeated bewilderment 
is deeply touching. Is her experience altogether excep- 
tional and uncommon? Alas, no. 

In my work for the state I talk with patients, or 
ex-patients, and review their records. All the patients 
have undergone treatment, often surgical. In one lan- 
guage or another they comment, freely for the most part, 
on the treatment received. Don’t look for compliments; 
this is the group for whom medical efforts have failed. 
Yet anger, as described by Ms Kendrick, seems absent. If 
it’s there, concealed, balance returns with the striking expres- 
sions of faith some of the patients have in their doctors. 
The stories are rarely dull and occasionally reach the 
poignancy of Ms Kendrick’s recital. One often wishes the 
caregiver were there to hear. 

Ms Kendrick would like “to open communication 
between the medical profession and patient.” Fine. For 
physicians the lines of communication are open and 
abundant. How is the patient to communicate? Do we 
know his, or her, views with any certainty? 

Let’s invite the volunteer corps of our various hospi- 
tals to a new challenge. Each volunteer group is likely to 
contain one or two dedicated individuals who’ll be in- 
trigued. In some sort of random selection, hospitalized 
patients will be interviewed by the volunteers to explain 
the study and establish individual liaison. Consent, ob- 
viously, will be required of both patient and attending 
physician. After the patient’s discharge the volunteer 
keeps in touch by telephone, in time becoming familiar 
with the patient’s considered view of his course. To this 
point the study may resemble the follow-up question- 
naires hospitals sometimes send to discharged patients. 
But what’s sought here is the patient’s unframed, mature 
evaluation of treatment received and its effect. When the 
picture becomes focused it’s put into story form by the 
volunteer, all names omitted and using the patient’s own 
words as much as possible. Then the story is submitted to 
the Journal for publication. 

Will all this effort be worthwhile? Yes, according to 
Ms Kendrick. She states, meeting no objection from this 
quarter, that “Life experience speaks clearly, it is our 
greatest teacher.” 

Russell V. Fuldner, M.D. 

Hamden, CT 


Edward Luchansky, M.D., a Fairfield obstetrician/ 
gynecologist recently was re-elected as vice-president of 
the Civil Aviation Medical Association. This organiza- 
tion, composed of aviation medical examiners and air- 
line medical directors from all over the world, is con- 
cerned with the health and well-being of all civilian pilots 
and with the promotion of public aviation safety. Dr. 
Luchansky is a Federal Aviation Administration Senior 
Aviation Medical Examiner and serves as a flight sur- 
geon in the Civil Air Patrol. 

The Hartford County Medical Association has sche- 
duled Medical Expo ’89 for 5 and 6 April at the Hartford 
Civic Center. This will be the fourth year that Hartford 
County physicians have sponsored the region’s premier 
medical and health exhibition in efforts to make availa- 
ble the latest information on key issues facing the health 
care community. 

The symposia program this year is entitled, “On the 
Leading Edge,” and will focus on two areas of research 
that have been the subjects of almost daily headlines in 
the news: heart disease and cancer. Expo ’89 will high- 
light recent developments with a program that will 
explore: Innovative Cancer Treatments via Biotherapy; 
the debate on Whether the Costs of New Technology in 
the Treatment of Cancer and Heart Disease Are Justified 
by the Benefits; New Drugs in the War Against Cancer & 
Heart Disease; and the AMA nationwide Campaign 
Against Cholesterol. 

Throughout the two days of Medical Expo ’89, an 
estimated 250 exhibitors will show their products and 
services. The exhibition will also feature extensive nurs- 
ing recruitment activities of hospitals and health care 
facilities from throughout New England. 

A symposium entitled, Safety of the Blood Supply, 
will be held in Farmington, at the American Red Cross 
Connecticut Region on Wednesday, 12 April 1989 from 
noon to 5:00 p.m. This symposium, to be moderated by 
Dr. Edward L. Snyder, is designed to inform physicians 
and allied health care professionals about the safety of 
the blood supply and methods used to decrease the risk 
of disease transmission. The symposium is jointly spon- 
sored by Yale University and the American Red Cross 
Connecticut Region. Fee: $20.00. 

Those interested should call the Office of Graduate 
and Continuing Education, Yale University School of 
Medicine, 333 Cedar Street, P.O. Box 3333, New Haven, 
06511; or call (203) 785-4578. 

The 25th Annual Cardiovascular Symposium spon- 
sored by the Section of Cardiology, Saint Francis Hospi- 
tal and Medical Center, will be held at the Hunt Memor- 
ial, Hartford Medical Society, 230 Scarborough St., 
Hartford, on 3 and 4 May, 1989. The fee is $80.00. Those 
interested should contact Robert M. Jeresaty, M.D., 
Director, Section of Cardiology, Saint Francis Hospital 
and Medical Center, 1 14 Woodland St., Hartford 06105. 

VOLUME 53, NO. 2 



CARTER, MAX G., Harvard, 1941. Dr. Carter was a 
thoracic and cardiovascular surgeon in the New Haven 
area since 1949. He was a member of the New Haven 
County Medical Association, the Connecticut State Med- 
ical Society and the American Medical Association; died 
16 January 1989 at the age of 73. 

CUSHMAN, LAURENCE A., Harvard, 1924. Dr. Cush- 
man was a general practitioner in the Hartford County 
area since 1928. He was a member of the Hartford 
County Medical Association and the Connecticut State 
Medical Society; died 28 December 1988 at the age of 91. 

FINK, MARTIN E., State University of New York, 
1957. Dr. Fink was an internist in the New Haven 
County area since 1960. He was a member of the New 
Haven County Medical Association, the Connecticut 
State Medical Society and the American Medical Asso- 
ciation; died 8 November 1988 at the age of 60. 

LANSE, STEVEN B., SUNY at Buffalo, 1977. Dr. 
Lanse was an internist in the New Haven County area 
since 1982. He was a member of the New Haven County 
Medical Association, the Connecticut State Medical 
Society and the American Medical Association; died 6 
November 1988 at the age of 37. 

MACGREGOR, JAMES, University of London, 1928. 
Dr. Macgregor was a general practitioner in the Fairfield 
County area since 1955. He was a member of the Fair- 
field County Medical Association and the Connecticut 
State Medical Society; died 1 1 November 1988 at the age 
of 84. 

MCKEON, JAMES J., Hahnemann, 1939. Dr. McKeon 
was a general practitioner in the New Haven County 
area since 1940. He was a member of the New Haven 
County Medical Association and the Connecticut State 
Medical Society; died 1 1 November 1988 at the age of 76. 

OSTER, KURT A., University of Cologne, 1934. Dr. 
Oster was an internist in the Fairfield County area since 
1943. He was a member of the Fairfield County Medical 
Society, the Connecticut State Medical Society and the 
American Medical Association; died 24 November 1988 
at the age of 79. 

PACE, SILVIO F., University of Rome, 1952. Dr. Pace 
was a general practitioner in the Hartford County area 
since 1958. He was a member of the Hartford County 
Medical Association, the Connecticut State Medical 
Society and the American Medical Association; died 6 
November 1988 at the age of 62. 


REYNOLDS, ROBERT G., Harvard, 1926. Dr. Rey- 
nolds was an orthopedic surgeon in the Hartford County 
area since 1927. He was a member of the Hartford 
County Medical Association and the Connecticut State 
Medical Society; died 22 December 1988 at the age of 90. 

SCHECHTMAN, CHARLES T., University of Ver- 
mont, 1926. Dr. Schechtman was an ophthalmologist in 
the Hartford County area since 1930. He was a member 
of the Hartford County Medical Association, the Con- 
necticut State Medical Society and the American Medi- 
cal Association; died 1 January 1989 at the age of 88. 

SMITH, JAMES T., Long Island College of Medicine, 
1941. Dr. Smith was a general surgeon in the Litchfield 
County area since 1947. He was a member of the Litch- 
field County Medical Association, the Connecticut State 
Medical Society and the American Medical Association; 
died 30 November 1988 at the age of 75. 

SMITH, JOSEPH J., University of Maryland, 1930. 
Dr. Smith was an internist in the Fairfield County area 
since 1933. He was a member of the Fairfield County 
Medical Association, the Connecticut State Medical 
Society and the American Medical Association; died 21 
November 1988 at the age of 84. 

SONGCO, MARIANO F., University of the Philip- 
pines, 1954. Dr. Songco was a psychiatrist in the New 
London County area since 1958. He was a member of the 
New London County Medical Association and the Con- 
necticut State Medical Society; died 6 January 1989 at 
the age of 60. 

WEED, CLAYTON B., JR., New York Medical Col- 
lege, 1947. Dr. Weed was an internist in the Fairfield 
County area since 1948. He was a member of the Fair- 
field County Medical Association and the Connecticut 
State Medical Society; died 15 January 1989 at the age of 

ZSIGA, ELMO D., Marquette, 1938. Dr. Zsiga was a 
general practitioner in the Fairfield County area since 
1938. He was a member of the Fairfield County Medical 
Association and the Connecticut State Medical Society; 
died 4 November 1988 at the age of 72. 


From the Executive Director’s Office 


Wednesday, January 11, 1989 


Present in addition to the Chairman Dr. Joseph C. 
Czarsty and Vice-Chairman Dr. Joseph S. Sadowski 
were Drs. Ahamed, Beck, Bobruff, Bonner, Chmieleski, 
Eslami, Freedman, Hollister, Kamens, Kaufmann, 
McDonnell, Orphanos, Robbins, Schwartz, Van Syckle, 
Welch, Wetstone, Zanker, Zeppieri and Zlotsky. 

Also present: Mr. Norbeck, Mrs. Lindquist, Mr. Bru- 
nell, Mr. Sullivan, Mr. Staples, Mr. Tomat (FCMA), 
Mr. Coffee (HCM A), Mr. Freberg(NHCMA) and Mrs. 
Reed (President, Auxiliary). 

Absent were: Drs. Catrini, Dardick, Fox, 111, O’Brien, 
Petrie, Reyelt, Jr., Rose, Rubin, Sosa, Upham and Villa. 

Dr. Joseph C. Czarsty, Vice-Chairman of the Council 
called the meeting to order, since Dr. Guy W. Van 
Syckle, whose term as Delegate to the AM A terminated 
on 12/31/88, thereby was no longer a member of the 

Councilor- At-Large 

Dr. Czarsty called on Dr. James P. Orphanos, Coun- 
cilor-at-Large and Alternate Delegate to the AM A, who 
submitted a resolution which outlined that he held a dual 
position on the Council and that Dr. Van Syckle’s exper- 
ience and wisdom should not be lost to the Council, he 
requested that the Council waive normal procedures, not 
to be interpreted as precedent setting, and accept his 
motion, “that it, in one unanimous vote, nominate, 
second and elect Dr. Van Syckle to the seat of Councilor- 
at-Large for the period effective immediately to the date 
of the 1989 Annual Meeting of this Society while simul- 
taneously accepting his resignation vacating that seat in 
Dr. Van Syckle’s favor.” It was VOTED to unanimously 
approve the motion. 

Election of Chairman and Vice-Chairman of the Council 

It was VOTED to unanimously elect Joseph C. Czarsty, 
M.D., Oakville, Chairman and Joseph S. Sadowski, 
M.D., Hartford, Vice Chairman. 

Presentation to Guy W. Van Syckle, M.D. 

Norman A. Zlotsky, M.D., President, presented the 
following resolution to Dr. Van Syckle: 

“Whereas: Guy W. Van Syckle, M.D., has served the 
Council with distinction as its chairman from 1981 until 
his retirement from the AMA delegation effective De- 
cember 31, 1988; and 

Whereas: Dr. Van Syckle has ably served the Connecti- 
cut State Medical Society as a delegate to the AMA, the 
chairman of its delegation and chairman, as well, of the 
New England delegation; therefore be it 
RESOLVED:That the Council formerly acknowledges 
the substantial contributions which Guy W. Van Syckle, 
M.D., has made to all facets of medicine and wishes him 
well in his future endeavors.” 

Dr. Van Syckle addressed the Council briefly express- 
ing his pleasure in working with members of the Council, 
presidents and staff during his term as Chairman of the 
Council. He reported that CSMS should be proud of its 
many achievements, especially the development of the 
Connecticut Medical Insurance Company (CMIC), 
CPRO and M.D. Health Plan, which have received 
national recognition. 

Committee on Legislation 

Dr. Czarsty submitted his resignation as chairman of 
the Committee on Legislation and it was VOTED to 
approve Dr. Zlotsky’s nomination of Howard J. Whet- 
stone, M.D., Hartford, as chairman. 

Physicians Serving on State and Federal Agencies 

Roger Beck, M.D., CSMS representative for the 
Department of Health Services Ad Hoc Committee on 
Prescriptive Authority for Nurses, reported that this is a 
very controversial subject and gave the following back- 
ground information: The committee is made up of one 
physician, two pharmacists, about six nurses plus a 
representative from the state narcotics division and an 
attorney for the state who also happens to be a nurse. 
The issue of prescriptive authority for nurses was raised 
by an HMO who requested the narcotics division to 
grant that their nurse practitioners be allowed to pre- 
scribe. The request was submitted to the Attorney General 
who determined that this practice would be illegal. This 
determination was not welcomed by the Division of 
Community Services and Home Health Care of the State 
Department of Health Services. It appears that there are 
nurse practitioners prescribing now in numerous loca- 
tions with and without the sanction of the state in various 
clinics, nursing homes, schools, colleges, etc. It has 
become apparent that the Department of Health Servic- 
es will attempt to change the statutes to include nurse 
prescriptive authority, therefore, a statement of condi- 
tions concerning the broadening of the statute was de- 
veloped by CSMS representatives and legislative counsel 
and given to the Department of Health Services and it is 
hoped that they would adhere to these recommenda- 

VOLUME 53, NO. 2 


tions. Any legislation introduced concerning this subject 
will be monitored by the responsible CSMS legislative 
representatives. The complete report outlining the re- 
strictions was distributed to members of the Council. In 
essence, nurse practitioners, who would have to meet 
certain educational standards, will be able to prescribe 
within certain parameters and conditions and would not 
be able to prescribe any narcotics. It was VOTED to 
approve the report. It was VOTED that Sullivan and 
Le Shane and the proper CSMS representatives be re- 
quested to work to clearly specify the liability responsi- 
bility of the advance practice registered nurse in their 
prescriptive activities. 

Edward Kamens, M.D., Chairman of the Governor’s 
Task Force on the Evaluation of Prospective Payment 
Systems for the State of Connecticut, reported that 
before filing their annual report, the Task Force had the 
opportunity to listen to reports from many sources, i.e., 
the hospitals, VNA, Home Health agencies, etc., all of 
which are under major stress at the present time because 
of the great need for extended and home health care. As 
of the present, there is no factual information on the 
quality of care and how it has been affected by technol- 
ogy. The report filed is public information and available 
to any one who wishes to read it. 

Dr. Kamens also reported as Medical Director of 
CPRO, that the quality of care continues to be at a high 
level. Almost 40% of the charts are flagged and reviewed 
and the denial rate is at 3-1 / 2% at the present time. It was 
down to 2% when there were pre-admission require- 
ments. Most of the shortcomings in the charts reviewed 
come from documentation. Despite all efforts made, that 
factor continues to be a problem. There have been 1 1 
sanctions in Connecticut (18 physicians and three hospi- 
tals), and there have been no repeat offenders. He urged 
that quality assurance programs in the hospitals be more 
diligent in their reviews. The hospitals that have active 
quality assurance programs are doing an excellent job. 

He further reported that once again Connecticut has 
been selected to participate in a project, this time by 
American Medical Research Review Organization. The 
project has to do with small area analysis. This is a study 
of physician patterns within regions of the state based on 
the concept of population within certain demographic 
areas. He urged physicians that, if requested, they partic- 
ipate in this study. 

Report of the President 

Dr. Zlotsky reported on the following items: 

1989 Surveys of Physician and Public Opinion — A letter 
was received from the AMA inviting state medical socie- 
ties to participate in the AMA’s 1989 surveys of physi- 
cian and public opinion on a variety of issues related to 
Medicare, the public image of physicians, peer review, 
issues in biomedical research, technology and the cost of 
care. It was reported that although the public survey 
would be useful, because of other CSMS priorities and 

the expense involved, this be considered for future years. 

COM PA C — It was reported in the final AMPAC report 
that Connecticut was rated 19th in the country in all 
categories with 28% in attainment of membership. More 
importantly, the percentage of sustaining members in 
Connecticut is very significant and ranks almost first in 
the country. Consideration is being given to the publica- 
tion of a brochure outlining the CSMS position on the 
many issues that are coming before the legislature. 
President’s Dinner — The dinner was held on November 
9, 1988 and it was very successful. This year section 
presidents were invited for the first time. The CSMS 
lobbyist gave an overview of the various issues that 
would be coming before the legislature, and a list was 
developed of physicians who would be interested in 
assisting the lobbyist in testifying at the capitol. 

Tort Reform — Attorney Donald Elliott, Professor of 
Yale on Torts, was selected to pursue the issue of the 
constitutionality of a cap on non-economic damages. A 
preliminary report has been received and a meeting will 
be held on January 13 with the attorney and various 
CSMS members to review the report. 

CM MI Board — At the request of the Council the CM MI 
Board met on November 7, 1988. The purpose of the 
meeting was to discuss organizational relationship be- 
tween CSMS, CMMI and CMIC. Dr. Zlotsky reported 
that no subsequent decisions were made but were assured 
that a good faith effort would be made to keep a formal 
or informal connection between the CMMI and CMIC 

At this point, it was decided to discuss Agenda Item 
No. 10, which had to do with the meeting held between 
the CMMI, CMIC and CSMS leadership. Sultan 
Ahamed, M.D. reported that the CMIC Bylaw Commit- 
tee was going to consider incorporating into the Bylaws 
representation of CMMI Board Members on the CMIC 
Board. However, if this was not possible, the CMIC 
Board would agree to have four members of CMMI 
Board on their Board. This proposal would have to be 
done in cooperation with the county associations, be- 
cause the CMIC Directors are elected through the county 
association, and there is no direct representation from 
the CSMS Council. Since the CMMI Board is nomi- 
nated by the CSMS Council, one solution would be to 
have the CMIC Board contact the various county asso- 
ciations with representation on the CMMI Board and 
suggest that the individual serving on the CMMI Board 
be nominated as the county representative on the CMIC 
Board. Dr. Zlotsky stated that at the present time there is 
no guarantee that members of the CMMI Board will 
become members of the CMIC Board and hoped that a 
subsequent report would be made to the Council follow- 
ing the meeting of the CMIC Bylaw Committee. 

Report on CMMI 

James P. Orphanos, M.D., Chairman of the Board of 
CMIC, reported on the change-over of employees from 



CM MI to CMIC. It was stated that as of January 1, 
1989, CMIC had 2,400 policyholders which was an 
increase from 2,375 in October 1988, and represents 
almost 55% of the market. Staff has been increased and 
claims-made policies are still the only product available. 
He also included a report on the assets of the company, 
the success of the self-study course offered by the Risk 
Management Committee which gives the physicians a 
5% discount on the completion of the course and CME 
credits, practice seminars, support group sessions and 
the issue of federal taxes as they relate to insurance 
companies. It was reported that in late December 1988, a 
subsidiary of CMIC was formed and will be known as 
the Professional Liability Services Corporation with 
headquarters in Wallingford. This subsidiary was formed 
to insulate CMIC from possible liability for any of the 
ongoing operations that CMIC has been performing, as 
well as being able to separate expenses from the main 
insurance operation. 

Report of the Executive Director 

Tim Norbeck reported on the following items: 

Toll Free Telephone Number — After checking with other 
state societies, it was determined that those states that did 
have toll free numbers for their membership did not find 
it burdensome. 

Legislation — 1989 appears to be a year of measureless 
perils with such issues as nurse practitioners, podiatrists 
and physical therapists all attempting to expand their 
scope of practice, tort reform, expansion of mandatory 
assignment and many other items. 

HBO Screening of Film on Smoking — It was reported 
that this film on smoking by C. Everett Koop, M.D., 
Surgeon General, was excellent and is available to any 
individual or groups that wish to see it. 

Report of the Auxiliary 

Mrs. Joan Reed, President of the Auxiliary, reported 
that the group is having a day at the capitol in March and 
will be meeting with legislators and lobbyists and attend 
hearings. They are also working on a possible program 
for families of impaired physicians. A newsletter depict- 
ing some meaningful programs that have been under- 
taken by the Auxiliary will soon be mailed to non- 
members with the hope that it will stimulate some 
interest in membership. 

Report of AMA Delegation 

Jerome K. Freedman, M.D., reported that in answer 
to questions as to why AMA did not do something on 
the RBRVS, it is to be noted that the RBRVS was not an 
idea of the AMA but was mandated by Congress and the 
alternative to it was mandatory assignment. In an attempt 
to cut costs of the care of the elderly, RBRVS was only 
one of numerous proposals being considered. With one- 
half million subscribers being added to the Medicare 
rolls each year, containing costs is not an easy task. The 
AMA is doing its utmost in working with the other 
agencies involved in the RBRVS to provide an accept- 

able basis for a Medicare indemnity payment system. 
Drs. Kamens, Van Syckle and Orphanos also reported 
on the RBRVS, the area capitation system, Registered 
Care Technicians (RCPs) Antitrust regulations and sev- 
eral other issues. A detailed report had been submitted to 
all members of the Council prior to the meeting. 

M.D. Health Plan Report 

Douglas Hayward, President and CEO of M.D. 
Health Plan joined the Council to give a progress report. 
The recent stock offering was to increase capital and the 
number of participating physicians. Although 2,500 phy- 
sicians had contributed seed money to the CSMS-IPA in 
1986, only 1,600 followed through on their commitment 
to provide the necessary capital for the HMO; thus there 
was need to continue capitalization efforts. As of Janu- 
ary, 1989, there are nearly 12,000 M.D. Health Plan 
enrollees, and over 4,000 more in the joint venture with 
Stirling and Stirling, totalling 16,000 patients for our 
participating physicians already. Mr. Hayward antici- 
pates over 100,000 patient visits in 1989, generating more 
than $12,000,000 in physicians fees. 

Even after the new stock offering, the need for addi- 
tional funds was anticipated to maintain the state-re- 
quired $1,000,000 reserve. After discussions with the 
Insurance Department and considering several other 
options, the MDEC Board chose to raise the remaining 
capital internally in order to maintain the Society’s origi- 
nal objective of total physician control and ownership as 
established by the House of Delegates. Thus the IPA 
agreed to levy a membership fee of $250 for the most 
underrepresented specialties, and $500 for others, for this 
purpose. To address the need for additional physician 
coverage in some regions and specialties, CSMS-IPA 
also opened up participation to all remaining CSMS 
physicians without a stock purchase requirement, 
through the use of the new membership fee. This further 
enhances the Plan’s marketability and viability, and 
breakeven is now anticipated in the summer quarter of 

Resolution on Restraints Placed on Physicians by 
Claims Made Professional Liability Carriers 

It was VOTED to refer the above subject resolution, 
which was referred to the Council by the House of 
Delegates, to the Connecticut Medical Management, 
Inc. (CMMI) for study and report. The text of the 
resolution follows: 

“Resolved, That the CSMS Council investigate the pos- 
sibility of having a reciprocal agreement among profes- 
sional liability companies so that a physician may con- 
template establishment of a medical practice in another 
state without the purchase of tail coverage, thus allowing 
physicians more mobility from one state to another; and 
further be it 

Resolved, That the CSMS Council report on this sub- 
ject to the House of Delegates at its Annual Meeting in 
May 1989, and that the House of Delegates, at that time, 

VOLUME 53, NO. 2 


transmit its action to the Connecticut Medical Insurance 

Medical Courtesy Card 

It was VOTED to approve a letter presented by Dr. 
Zlotsky to be sent to editors of all major dailies inform- 
ing them that CSMS is urging physicians to honor the 
medical courtesy card beyond the deadline of December 
31, 1988 and to advise senior patients who have not 
applied for their ConnMap card to apply to the Depart- 
ment of Aging immediately. It has come to his attention 
that many seniors have not had their cards replaced by 
the State of Connecticut Medical Assistance Program. 

It was further VOTED that this information be trans- 
mitted to the membership as soon as possible. 

Report of AMA Resident Physician Section (RPS) 

At the request of the CSMS President that the 
CSMS/ RPS develop a position paper on the resident’s 
work hours in the state of Connecticut, the RPS voted 
unanimously to recommend to the Council the adoption 
of Report M of the AMA/ RPS with the exception of 
item #8. It was felt that these principles were consistent 
with AMA policy and would provide a firm foundation 
for CSMS policy in discussion of working hours. It was 
VOTED to approve this report and recommendation 
and send the report to the Committee on Legislation for 
their guidance. 

Universal Healthcare Insurance System 

It was VOTED to refer to the Committee on State- 
wide Medical Planning for study and report back to the 
Council at its next meeting, a communication received 
from Congressman Bruce Morrison’s Medical Advisory 
Committee seeking a proposal from CSMS for the struc- 
ture of universal healthcare insurance coverage in Con- 
necticut. It was suggested that AMA has information on 
the issue which may be helpful. 

Committee on Public Health 

Following discussion of a recommendation to the 
Council from the Committee on Public Health that the 
newly added phrase, “Except that such nurse, principal, 
or teacher may administer aspirin, ibuprofen or an 

aspirin substitute containing acetaminophen to any stu- 
dent at such school pursuant to the written authorization 
of a parent or guardian of such child,” be deleted from 
Section 10-2 12a, Connecticut General Statutes, as a- 
mended by Public Act 88-360, Section 47, it was VOTED 
to refer the subject to the Committee on State Legislation 
for action. 

U.S. Pharmacopeial Convention 

It was VOTED to appoint Michael L. Friedland, 

M. D., Bridgeport, as alternate delegate to subject 

Communication Re: RBRVS 

It was VOTED to receive as information a communi- 
cation from the Medical Center of Northeast Connecti- 
cut expressing their strong support for the Harvard 
Based Relative Value Scale study and to send a copy of 
the summary report of the AMA which discusses this 
issue back to this group for their information. 

Life Members 

It was VOTED to receive as information the following 
list of Life Members effective January 1, 1989: 

William P. Arnold, Jr., M.D., Middlebury (NH) 

Henry N. Blansfield, M.D., Danbury (F) 

John E. Borowy, M.D., Stamford (F) 

Eugene H. Corley, M.D., Bridgeport (F) 

John W. Geoghegan, M.D., West Hartford (H) 

Walter P. Gerent, M.D., West Hartford (H) 

Adrienne M. Krausz, M.D., Westport (F) 

John J. McDermott, M.D., Danbury (F) 

Alexander Menzer, M.D., West Hartford (H) 

John C. Moench, M.D., Guilford (NH) 

Hyman Nadel, M.D., Stamford (F) 

Richard C. Peterson, M.D., Stratford (F) 

Alexander H. Pinkes, M.D., North Branford (NH) 
Harold E. Rhame, Jr., M.D., Fairfield (F) 

Alan R. Small, M.D., Bridgeport (F) 

N. B.: The foregoing is a summary of the proceedings 

and actions of the Council on January 11, 1989. 
Detailed minutes of the meetings are on file at 160 
St. Ronan Street, New Haven, for perusal by any 
interested member of the Society. 



The Society maintains the Physician Placement Service as a service to the medical profession in Connecticut. 
Opportunities for physicians to locate in Connecticut will be published as space permits and will be distributed 
to physicians making inquiries of such opportunities. Information should be sent to 160 St. Ronan St., New 
Haven, CT 06511 (203-865-0587). 

Physicians wishing to establish practice in Connecticut are invited to submit a resume to be kept on file with 
the Society. An announcement of a physician's availability will be published in two issues of Connecticut 
Medicine as space permits. 

Listing of physicians in the Placement Service does not in any way represent certification by the Society. 
Investigation of credentials and experience is the responsibility of those seeking applicants for positions. 



Active Allergy Practice in large centrally located Connecticut city with 
large metropolitan population is available for sale. Also a small office 
building suitable for one or two doctors available on a sell or rent basis, 
within easy walking block to hospital or short drive to medical school. 
Reply to CSMS, AL/VG. 


Full-time positions in satellite and main emergency departments of 
JCAH-Approved 380-bed hospital, with residency program. Unique 
combination of emergency and urgent care medicine. Full hospital 
emergency department privileges. Paramedic base stations in both 
facilities. Beautiful shoreline area. Seek EM/ FP/ IM, BC/ BE individ- 
ual, ACLS, ATLS. ER experience preferred. Highly competitive salary 
and benefit package. Excellent work schedule. Contact Gordon Van 
Nes, M.D., Emergency Department, Middlesex Memorial Hospital, 
Crescent St., Middletown, CT 06457. (203) 344-6691. 

Park City Hospital in Bridgeport, CT is seeking full-time Emergency 
Medicine physician. Twenty-six thousand E.R. visits with Industrial 
Medical Center in E.R. Active Paramedic Program. Certification in 
ACLS and experience in Emergency Medicine required. First year 
compensation $96,000 with attractive benefit package. Send current 
CV to: Don Rankin, M.D., Emergency Department, Park City Hospi- 
tal, 695 Park Ave., Bridgeport, CT 06604 or call (203) 579-5040. 


Colchester — BC/BE Family Physician wanted to join busy solo Fam- 
ily Practice. Guaranteed income; good benefits; good coverage and no 
i obstetrics. Potential for partnership in two years. Please send CV to: 
Dr. Kassem M. Khybery, 79 Norwich Ave., Colchester, CT 06415. 

Excellent opportunity to join succesful residency trained solo practi- 
tioner on the beautiful Connecticut shoreline. Practice and lifestyle of 
the highest quality in this wonderful family community. Please reply to 
CSMS, c/o FP/UX. 


Practice for sale. One or two Internists or Family Practitioners to 
purchase established, active solo Primary Care practice, South Central 
Connecticut. Stately, spacious offices. Two open staff community 
hospitals close by. Please apply to CSMS, c/o FP/IM. 


Retired physician’s fully-equipped office, including X-ray, available for 
immediate rental or sale. Excellent location. Please reply: Judith 
Turetsky, 496 West McKinley Ave., Bridgeport, CT 06604. (203) 367- 
9300 for further information. 

Plant Physician. The Pfizer Inc. Chemical Production facility in 
Groton has an immediate need for a Physician to manage the Plant 
Medical Department which consists of seven employees. Duties include: 
Providing industrial health services to a facility of 1,800 employees; 
providing treatment and referral for emergencies and occupational 
illnesses and injuries; developing innovative medical programs to 
address employee health and safety issues; providing support in disabil- 
ity return-to-work program, EAP, and case management. The success- 
ful candidate will have an MD degree and license to practice medicine; 
strong management and interpersonal skills; experience in an industrial 
or military setting a plus. We offer an excellent compensation and 
benefits package. Please send your resume in confidence with salary 
requirements to: Mr. Barton S. Finegan, Director of Employee and 
Community Relations, Pfizer, Inc., Eastern Point Rd., Groton, CT 
06340. EOE. 

Free-basis, part-time, physicians needed to assist in physical examina- 
tions at the New Haven Military Entrance Processing Station. Ideal for 
retired family practitioners, internists and pediatricians. MD’s or DO’s 
must be licensed in a state or territory of the United States, DC or PR. 
No malpractice insurance needed. $125.00 to $150.00 for short morn- 
ing. Call Dr. Gerhard Mack (203) 787-3823 or write: Commander, New 
Haven MEPS, 150 Court St., 4th floor. New Haven, CT 06510-2056. 

Physician in practice for 30 years seeking part-time employment possi- 
bly leading to full-time employment in reviewing charts, hospital 
records and claims. Write, CSMS, c/o MS/ LB. 


Recently trained, solo, OB/ GYN, Board Certified seeks BE/BC asso- 
ciate for busy private practice in a beautiful resort community in 
southern Connecticut. Excellent opportunities for higher education, 
water recreation, and shopping. Easy access to New York City, 
Boston, Hartford and Cape Cod. Very stable economy with low 
unemployment. Would consider two physicians relocating together. 
Please forward CV to: Stanley P. Solinsky, M.D., 350 Montauk Ave., 
New London, CT 06320. 


Ophthalmology Practice. Seeking colleague to assume full responsibil- 
ity soon. Send CV to CSMS, c/o OPH/KN. 

VOLUME 53, NO. 2 



(potassium chloride) Sustained Release Tablets 


1 . For therapeutic use in patients with hypokalemia with or without metabolic alkalosis, in digitalis 
intoxication and in patients with hypokalemic familial periodic paralysis. 

2. For the prevention of potassium depletion when the dietary intake is inadequate in the following 
conditions: Patients receiving digitalis and diuretics for congestive heart failure, hepatic cirrhosis 
with ascites, states of aldosterone excess with normal renal function, potassium-losing nephropathy, 
and with certain diarrheal states. 

3. The use of potassium salts in patients receiving diuretics for uncomplicated essential hyperten- 
sion is often unnecessary when such patients have a normal dietary pattern. Serum potassium 
should be checked periodically, however, and if hypokalemia occurs, dietary supplementation with 
potassium-containing foods may be adequate to control milder cases. In more severe cases sup- 
plementation with potassium salts may be indicated. 

CONTRAINDICATIONS: Potassium supplements are contraindicated in patients with hyperkalemia 
since a further increase in serum potassium concentration in such patients can produce cardiac 
arrest. Hyperkalemia may complicate any of the following conditions: Chronic renal failure, systemic 
acidosis such as diabetic acidosis, acute dehydration, extensive tissue breakdown as in severe burns, 
adrenal insufficiency, or the administration of a potassium-sparing diuretic (e g., spironolactone, 

Wax-matrix potassium chloride preparations have produced esophageal ulceration in certain cardi- 
ac patients with esophageal compression due to enlarged left atrium. 

All solid dosage forms of potassium chloride supplements are contraindicated in any patient in 
whom there is cause for arrest or delay in tablet passage through the gastrointestinal tract. In these 
instances, potassium supplementation should be with a liquid preparation. 

WARNINGS: Hyperkalemia— In patients with impaired mechanisms for excreting potassium, the ad- 
ministration of potassium salts can produce hyperkalemia and cardiac arrest. This occurs most com- 
monly in patients given potassium by the intravenous route but may also occur in patients given 
potassium orally. Potentially fatal hyperkalemia can develop rapidly and be asymptomatic. The use of 
potassium salts in patients with chronic renal disease, or any other condition which impairs potas- 
sium excretion, requires particularly careful monitoring of the serum potassium concentration and 
appropriate dosage adjustment. 

Interaction with Potassium Sparing Diuretics— Hypokalemia should not be treated by the con- 
comitant administration of potassium salts and a potassium-sparing diuretic (e.g. , spironolactone or 
triamterene) since the simultaneous administration of these agents can produce severe hyperkalemia. 

Gastrointestinal Lesions— Potassium chloride tablets have produced stenotic and/or ulcerative 
lesions of the small bowel and deaths. These lesions are caused by a high localized concentration of 
potassium ion in the region of a rapidly dissolving tablet, which injures the bowel wall and thereby 
produces obstruction, hemorrhage or perforation. 

K-DUR tablets contain micro-crystalloids which disperse upon disintegration of the tablet. These 
micro-crystalloids are formulated to provide a controlled release of potassium chloride. The dispersi- 
bility of the micro-crystalloids and the controlled release of ions from them are intended to minimize 
the possibility of a high local concentration near the gastrointestinal mucosa and the ability of the KCI 
to cause stenosis or ulceration. Other means of accomplishing this (e.g., incorporation of potassium 
chloride into a wax matrix) have reduced the frequency of such lesions to less than one per 100,000 
patient years (compared to 40-50 per 100,000 patient years with enteric-coated potassium chloride) 
but have not eliminated them. The frequency of Gl lesions with K-DUR tablets is, at present, 
unknown. K-DUR tablets should be discontinued immediately and the possibility^ bowel obstruction 
or perforation considered if severe vomiting, abdominal pain, distention, or gastrointestinal bleeding 

Metabolic Acidosis— Hypokalemia in patients with metabolic acidosis should be treated with an 
alkalinizing potassium salt such as potassium bicarbonate, potassium citrate, potassium acetate, or 
potassium gluconate. 

PRECAUTIONS: The diagnosis of potassium depletion is ordinarily made by demonstrating hypokale- 
mia in a patient with a clinical history suggesting some cause for potassium depletion. In interpreting 
the serum potassium level, the physician should bear in mind that acute alkalosis per se can produce 
hypokalemia in the absence of a deficit in total body potassium while acute acidosis per se can in- 
crease the serum potassium concentration into the normal range even in the presence of a reduced 
total body potassium. The treatment of potassium depletion, particularly in the presence of cardiac 
disease, renal disease, or acidosis requires careful attention to acid-base balance and appropriate 
monitoring of serum electrolytes, the electrocardiogram, and the clinical status of the patient. 

Laboratory Tests: Regular serum potassium determinations are recommended. In addition, during 
the treatment of potassium depletion, careful attention should be paid to acid-base balance, other 
serum electrolyte levels, the electrocardiogram, and the clinical status of the patient, particularly in 
the presence of cardiac disease, renal disease, or acidosis. 

Drug Interactions: Potassium-sparing diuretics; see WARNINGS. 

Carcinogenesis, Mutagenesis, Impairment of Fertility: Long-term carcinogenicity studies in 
animals have not been performed. 

Pregnancy Category C: Animal reproduction studies have not been conducted with K-DUR. It is 
also not known whether K-DUR can cause fetal harm when administered to a pregnant woman or can 
affect reproduction capacity. K-DUR should be given to a pregnant woman only if clearly needed. 

Nursing Mothers: The normal potassium ion content of human milk is about 13 mEq per liter. Since 
oral potassium becomes part of the body potassium pool, so long as body potassium is not exces- 
sive, the contribution of potassium chloride supplementation should have little or no effect on the 
level in human milk. 

Pediatric Use: Safety and effectiveness in children have not been established. 

ADVERSE REACTIONS: One of the most severe adverse effects is hyperkalemia (see CONTRAINDICATIONS, 
WARNINGS, and OVERDOSAGE). There have also been reports of upper and lower gastrointestinal 
conditions including obstruction, bleeding, ulceration, and perforation (see CONTRAINDICATIONS 
and WARNINGS); other factors known to be associated with such conditions were present in many of 
these patients. 

The most common adverse reactions to oral potassium salts are nausea, vomiting, abdominal dis- 
comfort, and diarrhea. These symptoms are due to irritation of the gastrointestinal tract and are best 
managed by taking the dose with meals or reducing the dose. 

Skin rash has been reported rarely. 

OVERDOSAGE: The administration of oral potassium salts to persons with normal excretory mecha- 
nisms for potassium rarely causes serious hyperkalemia. However, if excretory mechanisms are im- 
paired or if potassium is administered too rapidly intravenously, potentially fatal hyperkalemia can 
result (see CONTRAINDICATIONS and WARNINGS). It is important to recognize that hyperkalemia is 
usually asymptomatic and may be manifested only by an increased serum potassium concentration 
and characteristic electrocardiographic changes (peaking of T -waves, loss of P-waves, depression of 
S-T segment, and prolongation of the QT -interval). Late manifestations include muscle-paralysis and 
cardiovascular collapse from cardiac arrest. 

Treatment measures for hyperkalemia include the following: 

1. Elimination of foods and medications containing potassium and of potassium-sparing diuretics. 

2. Intravenous administration of 300 to 500 ml/hr of 10% dextrose solution containing 10-20 units 
of insulin per 1,000 ml. 

3. Correction of acidosis, if present, with intravenous sodium bicarbonate. 

4. Use of exchange resins, hemodialysis, or peritoneal dialysis. 

In treating hyperkalemia, it should be recalled that in patients who have been stabilized on 
digitalis, too rapid a lowering of the serum potassium concentration can produce digitalis toxicity. 

1002004 13944326 

Rev. 4/87 

# Key Pharmaceuticals, Inc. 

# 15 ##. Kenilworth, NJ 07033 (USA) 

World leader in drug delivery systems. 



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Ataxia Telangiectasia: A Familial Multisystem Disorder 


A TAXIA telangiectasia (AT) is a multisystem dis- 
order characterized by oculocutaneous telangiecta- 
sias, cerebellar degeneration, multiple immunologic ab- 
errations, spontaneous as well as induced chromosomal 
abnormalities, and a predilection for the development of 
various malignant neoplasms. Death, which usually oc- 
curs in the second decade, is due to infectious complica- 
tions or malignancy. 1 AT is inherited as a single-gene 
autosomal recessive trait. Within the United States, the 
frequency of homozygotes is approximately one in 
40,000. 2 The disease was first reported by Syllaba and 
Henner in 1926 3 and later described by Louis-Bar 4 in 
1941. The term ataxia telangiectasia was coined by 
Boder and Sedgwick in 1957; a year later they made the 
first observations on the syndrome’s pattern of inheri- 
tance, and noted itspredilection for children of families of 
European descent and its lack of sex prevalence. 5 * 6 
Ophthalmologic Manifestations 
Telangiectasias of the bulbar conjunctiva, most prom- 
inent in the medial and lateral canthal regions, usually 
appear between the ages of two and eight. 7 These dilated 
vessels have been shown to be of venous origin and 
usually remain unchanged throughout life. Most patients 
manifest the ophthalmologic signs of concurrent cerebel- 
lar degeneration such as nystagmus, absence of optoki- 
netic nystagmus, and apraxia of eye movements. 8 
Cutaneous Manifestations 

Telangiectasias of areas other than the bulbar conjuc- 
tiva do develop later, particularly in sun-exposed regions 
such as the ears, neck, butterfly area of the face, periorbit- 
ally, and in flexural folds of the extremities. These areas 
usually become involved before the age of ten. 9 In addi- 
tion, hyperpigmentation and hypopigmentation, particu- 
larly in telangiectatic areas, vitiligo, acanthosis nigricans, 
cafe-au-lait macules, seborrheic dermatitis, atopic der- 
matitis, xerosis, follicular hyperkeratosis, and hirsutism 
of the arms and legs are all more common in AT patients 
than the general population. Diffuse premature greying 
of the hair or white patches of hair, progeroid facies, and 
sclerodermoid and senescent features may also be seen. 9 * 10 

IRA SCHLESINGER, M.D., Third Year Resident, Internal Medi- 
cine, Greenwich Hospital, Greenwich, CT. 

Neurologic Manifestations 

The first sign of disease usually becomes apparent at 
one to one and one-half years of age because of difficulty 
with ambulation. Initial cerebellar findings may be mild 
and present only as unsteadiness of gait; however, the 
ataxia soon worsens and is accompanied by hypotonia, 
decreased deep tendon reflexes, intention tremor, and 
dysarthria. The cerebellar dysfunction is usually so severe 
that ambulation is impossible by age ten. Further neuro- 
logic degeneration presents with choreoathetosis, muscle 
atrophy, and Parkinsonian features of mask-like facies, 
rigidity, bradykinesia, and constant drooling. 8 The pri- 
mary pathologic central nervous system finding is diffuse 
cerebellar atrophy with a decrease in the number of 
Purkinje cells. 11 * 12 

Immunologic Manifestations 
The thymus of AT patients has the appearance of a 
fetal gland. A modest lymphopenia, cutaneous anergy, a 
decreased ratio of helper to suppressor T cells and a 
decreased production of cytotoxic T cells are manifesta- 
tions of the cellular immunologic defect. 13 Approximate- 
ly 70% of patients have a severe deficiency of IgA while 
approximately 80% have a severe IgE deficiency. Many 
patients have decreased concentrations of IgG-2 subclass 
and 80% have an abnormal low molecular weight IgM. 
The humoral abnormalities appear to be due to an inher- 
ent defect in B cells as shown by the fact that even stimuli 
which do not require T-helper cell activity lack an 
appropriate IgA response. 13 * 14 

Recurrent sinopulmonary infections are usually pres- 
ent by age three; however, oral candidiasis, impetigo, 
recurrent herpes labialis, disseminated herpes simplex, 
and chronic active hepatitis have all been reported. 10 * 15 
There is significant evidence for autoimmunity in AT 
patients. Antibodies to IgG, IgA, insulin receptors, and 
neural as well as thymic tissue have been reported. Anti- 
mitochondrial, antithyroglobulin, and antismooth mus- 
cle antibodies have been reported less frequently. 8 * 16 * 17 
Other less conclusive evidence includes the cutaneous 
findings of vitiligo and acanthosis nigricans. 

Laboratory and Associated Findings 
A lymphocyte count of less than 1,500 cells/ mm 3 is 

VOLUME 53, NO. 3 


not uncommon. Hepatic enzyme abnormalities include 
elevations of alkaline phosphatase, AST, ALT, and lac- 
tate dehydrogenase. Greater than 50% of patients have 
hyperglycemia, usually accompanied by elevated plasma 
insulin levels and insulin resistance. This effect has been 
attributed to the circulating inhibitor of insulin receptor 
binding. 16 Ovarian or testicular atrophy or complete 
absence of the ovaries is reported, and decreased urinary 
excretion of 17-ketosteroids is often present. 7 Accord- 
ingly, delayed growth and poor development of second- 
ary sex characteristics are common. 

The presence of elevated alpha-fetoprotein (AFP) and 
carcinoembryonic antigen (CEA) levels is characteristic 
of these patients. AFP and CEA are not normally pres- 
ent in high levels in adult serum; they are presumably 
secreted by poorly differentiated, immature cells. The 
elevated AFP is assumed to be due to the primary dis- 
order rather than to the accompanying features of AT 
that are known to increase AFP levels such as hepatoma, 
hepatitis, and testicular or ovarian tumors with embry- 
onic components. The elevated CEA is similarly assumed 
to be caused by AT itself rather than potential sequelae 
such as colonic carcinoma or hepatitis. 8 * 17 

Chromosomal Abnormalities 

Spontaneous translocations of chromosome 14 occur 
approximately forty times more often in AT lympho- 
cytes compared to normal cells. There is also a marked 
increase in spontaneous gaps, breaks, and fragments in 
lymphocyte chromatin of AT patients. 9 * 15 AT lympho- 
cytes have been shown to be extremely sensitive to 
acquired chromatin defects produced by radiation or 
mutagenic substances such as adriamycin and bleomy- 
cin. 18 A defect in the DNA repair process has also been 
elucidated. When normal cells are irradiated or damaged 
by mutagenic chemicals, they will enter a period of delay 
of initiation of DNA synthesis. This is presumably to 
allow for repair to occur so that chromosomal altera- 
tions are not reproduced. AT cells are deficient in this 
delay of DNA synthesis. 19 

This abnormal cellular sensitivity with deficient repair 
has been demonstrated clinically in the case of a nine- 
year-old male AT patient being treated with radiation for 
nasopharyngeal undifferentiated lymphoma. Radiation 
dermatitis, mucosal ulceration, and severe dysphagia 
were produced by one fourth of a dose that would be 
expected to produced such damage in a normal individu- 
al. 20 

Predisposition to Malignancy 

The risk for malignancy is 1,200 times greater in AT 
patients than in the normal population. 8 It is estimated 
that 10% of AT patients will develop at least one form of 
cancer during their lifetime. 21 Most reported neoplasms 
have been lymphoproliferative, such as Hodgkin’s and 
non-Hodgkin’s lymphoma, as well as lymphoblastic leu- 
kemias. Other malignancies such as astrocytoma, medul- 
loblastoma, ovarian dysgerminoma, gastric, renal cell, 

hepatic, basal cell, thyroid and pancreatic carcinomas 
have been reported. 1 * 21 * 22 In younger patients, lympho- 
proliferative neoplasms predominate while epithelial mal- 
ignancies are rare. Older patients display more epithelial 
neoplasms and rarely develop lymphoproliferative dis- 
orders. Longer survivors have been noted to suffer from 
multiple concurrent epithelial neoplasms. 21 

This marked predisposition toward malignancy may 
be explained by several mechanisms. Spontaneous and 
induced chromosomal abnormalities with inadequate 
repair may result in the chance production of a malig- 
nant clone of cells. Impaired cytotoxic T-cell immune 
surveillance could further allow malignant cells to prolif- 
erate. Although the spontaneous translocation of chromo- 
some 14 does not in itself explain malignant predisposi- 
tion, it may be compared to the Philadelphia chromosome 
and predisposition to chronic myelogenous leukemia. 15 
A connection also exists between chromosome 14 trans- 
locations and immune deficiency since both IgA and IgE 
are coded for on this chromosome. 1 


Because of the multifaceted nature of this disorder, it is 
difficult to propose one etiologic mechanism to explain 
all aspects of AT. Certain features, however, can be 
explained by less encompassing hypotheses. 

The defect in DNA stability and repair may explain 
many AT features including malignant predisposition, 
neurologic degeneration, telangiectasias, and progeroid 
skin and hair changes. Because neurologic tissues are not 
renewable, a defect in chromosomal stability may pre- 
dispose to premature cell death and tissue degeneration. 9 * 15 
Cutaneous regions, in daily contact with chemical and 
radiation insults, demonstrate signs of radiation damage 
and premature aging. 

Autoimmunity may explain some AT features which 
could not be attributed to chromosomal abnormalities 
alone. The circulating inhibitor of insulin receptor bind- 
ing is likely to be the cause of insulin resistance. 16 The 
antibodies to thymic and neural tissue may be responsi- 
ble for the poorly developed thymus and for cerebellar 
degeneration. 17 One function of the normal thymus is to 
educate T lymphocytes as to recognize self versus nonself 
tissues. It has been suggested that the aberrant thymus of 
AT patients may be causally related to the development 
of autoantibodies. 14 

In addition to chromosal instability and the autoim- 
munity hypotheses, a defect in mesodermal maturation 
may be present. Such a defect in tissue differentiation is 
suggested by the fetal thymus, elevated AFP and CEA 
levels, and poorly developed ovaries and testes or com- 
plete ovarian agenesis. 1 * 7 


AT heterozygotes are estimated to comprise 1% of the 
United States population. 2 Although some heterozygotes 
demonstrate cafe'-au-lait spots, most carriers do not 
present with any of the stigmata of AT. The significance 



of the occasional finding of cafe^au-lait macules is un- 
known since 10% of the normal population have this 
pigmentation. 10 

Shaham et al 23 found nearly normal rates of spon- 
taneous chromosomal breakage in heterozygote fibro- 
blasts, and Chen et al 24 found that AT carrier fibroblasts 
show a radiosensitivity intermediate between controls 
and homozygotes. Although there appears to be no con- 
sistent case for characteristic cutaneous findings or cyto- 
logic behavior in heterozygotes, the matter of malignant 
predisposition is not in question. AT heterozygotes under 
the age of forty-five are at a risk greater than five times 
that of the general population for dying of cancer. 
Greater than 5% of the population who die from a 
malignancy before age forty-five may be AT heterozy- 
gotes. Carriers seem particularly predisposed to ovarian, 
gastric, biliary, pancreatic, and colonic cancers, as well as 
leukemias and lymphomas. 2 


The immunodeficiency component of AT would ap- 
pear to be the aspect most amenable to medical interven- 
tion, but progress in this area has been disappointing. 
Gamma-globulin has proved of some benefit but only in 
patients with a specific deficiency of IgG-2 subclass and 
repeated infections. 14 Levamisole, a drug with both in 
vitro and in vivo evidence of T-lymphocyte stimulating 
properties may help in some patients, particularly in 
reducing bronchial secretions; 25 however, large scale clin- 
ical trials have not been attempted in AT patients. 
Thymosin-F5, which reportedly has T-lymphocyte stim- 
ulating properties, effects neither laboratory nor clinical 
improvement. 26 Transplantation of allogenic thymic tis- 
sue has not resulted in improvement of cell mediated 
immunity, although recent evidence suggests that a sim- 
ilar procedure when matched for HLA antigens may 
yield better results. 14 > 27 

The most effective therapy to date has been support- 
ive, consisting of physical therapy for recurrent pulmo- 
nary infections and appropriate antibiotic treatment for 
both pulmonary and other types of infection. 


1 . Weinstein S, Scottolini AG, Loo SY, Caldwell PC, Bhagavan NV: 
Ataxia telangiectasia with hepatocellular carcinoma in a fifteen- 
year-old girl and studies of her kindred. Arch Path Lab Med 
1985; 109: 1000^. 

2. Swift M, Sholman L, Perry M, Chase C: Malignant neoplasms in 
the families of patients with ataxia telangiectias. Cancer Research 

3. Syllaba L, Henner K: Contribution a Independence de Pathetose 
double idiopathique et congenitale: attiente familiale, syndrome 
dystrophique, signe du reseau vasculaire conjonctival, integrite 
psychique. Rev Neurol 1926;1:541-62. 

4. Louis-Bar D: Sur un syndrome progressif comprenant des telan- 
giectasies capillaires cutanees et conjonctivales symetriques, a dis- 
position naevoide et des troubles cerebelleux. Confina Neurol 

5. Boder E, Sedgwick RP: Ataxia-telangiectasia. A familial syn- 
drome of progressive cerebellar ataxia, oculocutaneous telangiec- 
tasia and frequent pulmonary infection. A preliminary report on 7 

children, an autopsy and a case history. Univ South Calif Med Bull 

6. Boder E, Sedgwick RP: Ataxia-telangiectasia. A familial syn- 
drome of progressive cerebellar ataxia, oculocutaneous telangiec- 
tasia and frequent pulmonary infection. Pediatrics 1958;21:526-54. 

7. Murphy S, Zwerdling R: Ataxia telangiectasia: A defect of tissue 
maturation and DNA repair. Cutis 1984;34:433-39. 

8. Smith LL, Conerly SL: Ataxia telangiectasia or Louis-Bar syn- 
drome. J Am Acad Derm 1985;12:681-96. 

9. Waldmann TA, Misiti J, Nelson DL, Kramer KH: Ataxia telan- 
giectasia: A multi-system hereditary disease with immunodefi- 
ciency, impaired organ maturation, x-ray hypersensitivity and a 
high incidence of neoplasia. Ann Int Med 1983;99:367-79. 

10. Cohen LE, Tanner DJ, Schaefer HC, Levis WR: Common and 
uncommon cutaneous findings in patients with ataxia telangiecta- 
sia. J Am Acad Derm 1984;10:431-38. 

11. Paula-Barbosa MM, Ruela C, Tavares MA, Pontes C, Saraiva A, 
Cruz C: Cerebellar cortex ultrastructure in ataxia telangiectasia. 
Ann Neuro 1983;13:297-302. 

12. Assencio-Ferreira VJ, Bancovsky I, Diament AJ, Gherpelli JL, 
Moreira FA: Computed tomography in ataxia telangiectasia. J 
Comput Assist Tomog 1981;5:660-1. 

13. Nelson DL, Biddison WE, Shaw S: Defective in vitro production 
of influenza virus-specific cytotoxic T lymphocytes in ataxia telan- 
giectasia. J Immunology 1983; 130:2629-34. 

14. Bridges BA, Harnden DG: Untangling ataxia telangiectasia. Nature 

15. Ben-Zvi A, Soffer D, Yatziv S: Disseminated herpes simplex virus 
infection in ataxia telangiectasia. Acta Pediatra Scan 1978;67: 

16. Bar RS, Levis WR, Rechler MM, Harrison LC, Siebert C, Pods- 
kalny J, Roth J, Muggeo M: Extreme insulin resistance in ataxia 
telangiectasia: Defect in affinity of insulin receptors. N Engl J Med 

17. Teplitz RL: Ataxia telangiectasia. Arch Neuro 1978;35:553-4. 

18. Bridges BA, Lenoir G,Tomatis L: Work-shop on ataxia telangiec- 
tasia heterozygotes and cancer. Cancer Research 1985;45:3979-80. 

19. Natarajan AT, Meijers M, van Zeeland AA, Simons JW: Attempts 
to detect ataxia telangiectasia (AT) heterozygotes by cytogenetical 
techniques. Cytogenet Cell Genet 1982;33:145-51. 

20. Abadir R, Hakami N: Ataxia telangiectasia with cancer. An indi- 
cation for reduced radiotherapy and chemotherapy doses. Bril J 
Rad 1983;56:343-5. 

21. Narita T, Takagi K: Ataxia telangiectasia with dysgerminoma of 
right ovary, papillary carcinoma of thyroid, and adenocarcinoma 
of pancreas. Cancer 1984;54:1113-6. 

22. Yoshitomi F, Zaitsu Y, Tanaka K: Ataxia telangiectasia with 
renal cell carcinoma and hepatoma. Virchows Arch [A] 1980; 

23. Shaham M, Voss R, Becker Y, Yarkoni S, Ornoy A, Cohn G: 
Prenatal diagnosis of ataxia telangiectasia. J Pediatr 1982; 100: 

24. Chen PC, Lavin MF, Kidson C, Moss D: Identification of ataxia 
telangiectasia heterozygotes, a cancer prone population. Nature 

25. Verhaegen H, DeCree J, Decock W, Verbruggen F: Restoration 
by levamisole of low E-rosette forming cells in patients suffering 
from various diseases. Clin Exp Immun 1977;27:313-8. 

26. Wara DW, Ammann AJ: Thymosin treatment of children with 
primary immunodeficiency disease. Transplant Proc 1978;10:203-9. 

27. Hong R: Correction of immune deficits by transplantation of 
cultured thymus. Prog Clin Bio Res 1981;58:185-90. 

VOLUME 53, NO. 3 


You don’t have time to waste on medical writing that is cluttered 
with complicated statistics and data. Depend on Postgraduate Medicine 
to provide you with clearly written, well-illustrated articles on matters 
{ of practical importance in your daily life. 

V j V ’ 

yjj W&PltomaKi 

Pancreatic Tuberculous Abscess 


ABSTRACT — Pancreatic tuberculous abscess is rare 
and has been reported only in the past five years. An 
association with the acquired immune deficiency syn- 
drome (AIDS) is suggested. Extensive drainage and 
appropriate antibiotic therapy is recommended. Intra- 
pancreatic abscesses should be cultured for M. tubercu- 
losis and, if identified, the patient should be studied for 
human immunodeficiency virus (HIV) infection. 


Intra-abdominal tuberculosis involving the pancreas 
is unusual. 1 Tuberculous pancreatic abscess has been 
described only twice in the English medical literature 2 ’ 3 
and this report presents one of only two published 

The data presented in this report suggest that this 
unusual occurrence may be a result of the weakened 
immunocompetence characteristic of the human im- 
munovirus syndrome and that such patients may be the 
harbingers of a recrudescence of unusual and challenging 
surgical problems reminiscent of the preantibiotic era. 

Case Report 

A 31 -year-old Haitian male who recently immigrated 
to the United States following a seven-year residence in 
French Guiana, presented with complaint of two to three 
weeks of midepigastric pain with radiation to the peri- 
umbilical area. He was anorectic and had lost 3 1 pounds 
in the last two months. All other gastrointestinal and 
respiratory symptoms were denied. He specifically denied 
intravenous drug use, homosexual, or prostitute contact. 
Physical examination was significant for an oral temper- 
ature of 38° C, shotty axillary and inguinal lymphadeno- 
pathy, and bilateral gynecomastia. Abdominal examina- 
tion revealed mild midepigastric and right upper quad- 
rant tenderness without guarding. There was no evi- 
dence of hepatosplenomegaly and no palpable mass. 
Testicular, prostate, and epididymal examination was 
unremarkable. Initial results revealed a white cell count 
of 8,400 with normal differential, serum amylase 150 

ALAN K. MEINKE, M.D., Assistant Attending; Department of 
Surgery, Norwalk Hospital, Norwalk, CT. 

Reprint requests to: Department of Surgery, Norwalk Hospital 
Norwalk, CT (Dr. Meinke). 

units (0-30), serum lipase 14 units (4-24), hemoglobin 9.5 
g, and sedimentation rate 92mm per hour. Multiple 
blood cultures were negative and hepatitis B surface 
antigen was nonreactive. Abdominal ultrasonography 
showed no abnormalities. His chest film revealed a right 
paratracheal mass. A computed tomographic scan of the 
abdomen (Figure 1) revealed a lobulated retrogastric, 
mixed attenuated, noncystic mass with enlarged periaor- 
tic lymph nodes and splenic enlargement. Reticulocyte 
count was 0.6, serum iron 7 ^ug/dL (40-135), total iron 
binding capacity 164 ;ug/dL (280-400), and alkaline phos- 
phatase 9 1 n l L (90-282). Morning and afternoon cortisol 
levels were with normal limits. Intradermal PPD was 
negative. Beta subunit of human chorionic gonadotropin, 
alphafeta protein, liver function tests, alpha 2 globulin, 
and urine analysis were all within normal limits. With the 
presumptive diagnosis of a malignant lymphoma or ret- 
roperitoneal tumor, the patient underwent an explora- 
tory laparotomy. A large mass of firm consistency was 
identified involving the pancreas and both the transverse 
colon and small bowel mesenteries. Frozen section exam- 
ination of numerous mesenteric lymph nodes revealed 
noncaseating inflammation. On freeing the posterior 
aspect of the stomach from the mass, approximately 
200mL of green, purulent material drained from within 
the pancreatic tissue. The area was widely drained and 
the patient was placed on broad-spectrum antibiotics. 
Postoperatively, he remained febrile and developed acute 
respiratory distress syndrome requiring ventilatory sup- 
port. When microbiologic evaluations of pancreatic pu- 
rulence revealed M. tuberculosis, he was treated with 
ethambutol, rifampin, isoniazid, and pyridoxine. His 
fever rapidly fell to normal and he was discharged from 
the hospital on the 20th postoperative day. He returned 
to full activities and continued to improve while being 
followed in the pulmonary outpatient clinic. Because of 
the unusual presentation of tuberculosis, permission was 
granted to test for HIV. Serum was found to be positive 
for antibodies using the immunoabsorbant assay. T4 
cells were absent. A repeat abdominal CT scan revealed 
resolution of the pancreatic mass (Figure 2). Six months 
following hospital discharge, the patient was readmitted 
with disseminated cryptococcus and expired. Blood, 

VOLUME 53, NO. 3 


cerebrospinal fluid, and bone marrow cuttings demon- 
strated C. neoformans. 


Duodenal obstruction resulting from peripyloric lym- 
phatic tuberculosis is well described 4 ’ 5 ’ 6 as is biliary 
obstruction from tuberculous adenitis. 7 Autopsy studies 
of miliary tuberculosis report pancreatic involvement 
ranging from 2.7%> to 20% 8 but clinical presentation of 
focal pancreatic tuberculosis is distinctly unusual 9 ’ 10 ’ 11 
and tuberculous pancreatic abscess has been described 

Figure 1 

Abdominal CT scan without intravenous contrast revealing a lobu- 
lated retrogastric mixed attenuated mass, enlarged periaortic lymph 
nodes, and splenic enlargement. 

only twice in the medical literature. 2 ’ 3 Both patients have 
presented since 1982 but before accurate tests to detect 
HIV were available. Because of this, neither was tested 
for HIV. 

Stambler 3 reported a 33-year-old Haitian women who 
presented with a fever, weight loss, weakness, and sple- 
nomegaly. As with our patient, an extensive work-up, 
including sputum and blood cultures as well as PPD skin 
testing, failed to suggest a tuberculous etiology. A CT 
scan of the abdomen revealed a pancreatic mass, and 
eventual exploration of the pancreatic head resulted in 
drainage of a tuberculous abscess. Despite proper anti- 
biotic therapy, the patient developed postoperative Kleb- 
siella pneumonitis and expired. 

Three years later, F. deMiguel published a case report 3 
of a 51 -year-old Caucasian man with similar complaints 
of fever and weight loss. Investigation failed to reveal the 
etiology of his fever. Exploratory laparotomy revealed a 
pancreatic abscess that was widely drained. When con- 
ventional antibiotics failed to reduce his fever, the possi- 
bility of tuberculosis was entertained and the subsequent 
treatment with appropriate antibiotics resulted in clinical 
improvement. Follow-up CT of the abdomen showed 
resolution of the pancreatic abscess with new onset of 
intra-abdominal lymphadenopathy. 

Our patient is the third to be reported with a pancre- 
atic tuberculous abscess. The preoperative diagnosis was 
intra-abdominal abscess or lymphoma. At laparotomy, 
the pancreas was firm to palpation and the diagnosis of 
pancreatic carcinoma was assumed. On mobilization of 

the pancreatic head, purulent material drained from 
within the pancreatic parenchyma. Finding acid-fast 
bacilli on smears secured the diagnosis. 

All three cases of pancreatic tuberculous abscess have 
been reported within the past five years. Widespread 
ability to detect HIV has developed only recently and its 
detection in our case suggests a correlation between this 
unusual presentation of tuberculosis and adult acquired 
immunodeficiency syndrome (AIDS). 

It has been well documented that tuberculosis may be 
the initial presenting manifestation in many patients who 
eventually demonstrate infection with the AIDS virus. 17 
Compared with the general population, there is a hun- 
dred-fold increase of tuberculosis among AIDS pa- 
tients. 18 This is particularly noted among Haitians with 
AIDS. 12 , 13 , 14 Although this increase is primarily due to 
M. tuberculosis, infection by the more unusual M. intra- 
cellularis and avium, 14 > 15 , 16 have also been identified. 

Many individuals with AIDS and tuberculosis present 
with overwhelming disease in advanced stages. In a 
recent series 16 of 136 patients with AIDS, 29 had severe 
and unusal manifestations of tuberculosis. This group 
was characterized by a lack of reaction to PPD skin 
testing and poor granuloma formation. Of these 29 
patients, 16 (55%) had disseminated disease and 21 (62%) 
presented with extrapulmonary disease. The national 
1980 tuberculous extrapulmonary rate was 14.2%. Extra- 
pulmonary tuberculosis has risen 10% between 1980 and 
1984, 16 likely reflecting the rising prevalence of AIDS in 
the population. 

Poor granuloma formation and poor reaction to intra- 
dermal PPD testing have been noted in other studies of 
tuberculosis in AIDS populations. 17 This delays recogni- 

Figure 2 

Abdominal CT scan showing resolution of pancreatic abscess. 

tion of infection and allows progression of the disease. 
As in the era prior to successful antibiotic treatment, 
these advanced forms of tuberculosis can present as 
surgical challenges both in diagnosis and treatment. 

It has been estimated that over 2 million Americans 
currently harbor HIV. 19 As clinical detection becomes 
more available, we anticipate its correlation with tuber- 
culous abscess will be more clearly defined. 



Until this correlation can be demonstrated, we suggest 
that cases of pancreatic abscess or any unusual intra- 
abdominal abscess be addressed with a differential diag- 
nosis which includes both tuberculosis and AIDS. Pa- 
tients presenting with unusual or aggressive manifesta- 
tions of tuberculosis should have serologic testing for 
AIDS and be followed for long periods of time to detect 
subsequent opportunistic infections. Appropriate pro- 
tective measures should be instituted. 

When intra-abdominal tuberculosis and AIDS are 
identified, conservative drainage and appropriate che- 
motherapy is recommended over resection. Results in 
our case and others, 14 support this recommendation. 


1. Auerback O: Acute generalized miliary tuberculosis. A J Pathol 

2. Stambler JR, Klibaner MI, Bliss CM, LaMont JT: Tuberculous 
abscess of the pancreas. Gastroenterology 1982;83:922-5. 

3. deMiguel F, Beltran J, Sabast JA, Sadaba F, Santamaria JM, 
Bustamante V: Tuberculous pancreatic abscess. Br J Surg\9%5,12\ 

4. Thompson JN, Keshavarzian A, Rees H: Duodenal tuberculosis. J 
R Coll Surg Edinb, 1982;29-5: 292-5. 

5. Ahmad M, Ahmed M: Duodenal tuberculosis. JPMA 1985; 

6. Keenan D: Tuberculous pyloric stenosis. Br J Surg 198 1 ;68:44. 

7. Murphy T, Gray G: Biliary tract obstruction due to tuberculous 
adenitis. A J Med 1980;68:452-4. 

8. Chapman CB, Wharton, CM: Acute generalized miliary tubercu- 
losis in adults. N Engl J Med 1946;235:230-48. 

9. Crowson MC, Perry M, Burden E: Tuberculosis of the pancreas; 
A rare cause of obstructive jaundice. B J Surg 1984;71 (3);239. 

10. Stock KP, Riemann JR, Stadler W, Rosch W: Tuberculosis of the 
pancreas. Endoscopy 1981;13:178-80. 

11. Chandrasekharg KL, Iyer SK, Stanek AE, Herbstman H: Pan- 
cratic tuberculosis mimicking carcinoma. Gastrointest Endosc 

1 2. DeLaLoma A, Manirque A, Ribio R, et al: Generalized tuberculo- 
sis in a patient with acquired immunodeficiency syndrome. J. 
Infect 1985;10:57-9. 

13. Goedert J, Weiss S, Biggar R, et al: Lesser AIDS and tuberculosis. 
Lancet 1985;July:52. 

14. Pitchenik AE, Cole C, Russell BW, Fischl MA, Spira TJ, Snider 
DE: Tuberculosis atypical mycobacteriosis and the acquired im- 
munodeficiency syndrome among Haitian and non-Haitian pa- 
tients in South Florida. Ann Intern Med 1984;101:641-5. 

15. Roth RI, Owen RL, Keren DF, Volberding PA: Intestinal infec- 
tion with Mycobacterium avium in acquired immunodeficiency 
syndrome. Dig Dis Sci 1985;30:497-504. 

16. Sunderham G, McDonald RJ, Maniatis T, Oleske J, Kapila R, 
Reichman LB: Tuberculosis as a manifestation of the acquired 
immunodeficiency syndrome. JAMA 1986;256:362-6. 

17. Pitchenik AE, Rubinson HA: The radiographic appearance of 
tuberculosis in patients with the acquired immune deficiency syn- 
drome and pre-AIDS. Am Rev Respir Dis 1985;131:393-6. 

18. Hadler JL, Burger R: Tuberculosis and AIDS-Connecticut. Conn 
Med 1987;51:384-5. 

19. Selwyn PA: AIDS: What is now known in epidemiology. Hosp 
Prac 1986;June: 127-64. 


Members of the Connecticut State Medical Society reading papers before other 
organizations are requested to submit their papers to the JOURNAL for consideration by 
the Board of Editors for publication. Authors preparing manuscripts for submission to 
Connecticut Medicine should consult INFORMATION FOR AUTHORS. This mater- 
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delays both in acceptance and in publication. 

Please send them to: Robert U. Massey, M.D., Editor 

Connecticut Medicine 

160 St. Ronan Street 

New Haven, Connecticut 06511 

VOLUME 53, NO. 3 


Internal Carotid Artery Aneurysm: A Vascular Manifestation 
of Type IV Ehlers-Danlos Syndrome 



ABSTRACT— Aneurysms of the distal internal carotid 
artery (ICA) can be difficult to manage. When seen in a 
patient with Ehlers-Danlos Syndrome, type IV (EDS- 
Type IV), the complexity of the problem is greatly 
increased. Proximal ICA ligation in the presence of an 
intact circle of Willis and adequate collateral circulation 
is a reasonable and safe approach. We recommend the 
liberal use of duplex scanning and intravenous digital 
angiography in patients with EDS, and plan to use these 
techniques to follow the small, asymptomatic, right ICA 
aneurysm in our patient. If the aneurysm rapidly grows 
or becomes symptomatic, treatment may require prox- 
imal ligation with extracranial-intracranial bypass. Un- 
derstanding of the basic defects associated with EDS- 
Type IV will make the management of patients with 
vascular complications more safe. 


T HE Ehlers-Danlos syndrome (EDS) is a group of 
heterogeneous genetic disorders of collagen, which 
in some forms is manifested by complex and often life- 
threatening vascular complications. Knowledge of the 
various types of vascular lesions seen in EDS will aid the 
vascular surgeon with the management of patients with 
this rare set of disorders. EDS is currently divided into 
eleven different types based on biochemical criteria and 
phenotypic expression. 1 Several previous reports in the 
literature provide excellent documentation of the arterial 
complications, but lack biochemical verification of the 
specific subtype of EDS. Recent experience with a patient 
at the University of Connecticut Health Center with 
well-documented EDS-Type IV prompted this case re- 
port and a review of the vascular complications of EDS. 

STEVEN T. RUBY, M.D., Assistant Professor of Surgery, Depart- 
ment of Surgery, University of Connecticut School of Medicine; 
JONATHAN KRAMER, M.D., Assistant Professor, Department of 
Radiology, University of Connecticut School of Medicine; SUZANNE 
B. CASSIDY, M.D., Associate Professor, Department of Pediatrics, 
Section of Genetics Dysmorphology, University of Arizona; PETROS 
TSIPOURAS, M.D., Associate Professor, Department of Pediatrics, 
University of Connecticut School of Medicine, Farmington, CT. 

Case Report 

K.D., a 22-year-old female with EDS-Type IV, was 
referred to the vascular surgery clinic at the University of 
Connecticut Health Center with a five-month history of 
transient left eye blindness. The episodes occurred sev- 
eral times per week, lasted from one to ten minutes, and 
were described as gradually increasing darkness until 
there was no vision at all. Pain in the left eye would often, 
but not always, accompany these episodes, and her 
vision was always normal between episodes. She denied 
any other neurological symptoms. A diagnosis of EDS- 
Type IV had been made clinically at age 16 and was 
confirmed biochemically at age 20, when cultured fibro- 
blasts from a skin biopsy failed to secrete Type III pro- 
collagen. 1 She had a history of varicose veins, bruised 
easily, had thin skin, and hyperextensible joints. At age 
20, she had an uneventful pregnancy and cesarean sec- 
tion delivery of a female infant. Previous publications 
detail her biochemical findings 1 and pregnancy man- 
agement. 2 Her mother had EDS and died suddenly at 
home at age 41. Her sister also has EDS. 

Physical examination was remarkable for thin skin, 
visible subcutaneous veins, hyperextensible small joints, 
and normal appearing scars. There were no cervical 
bruits, and her neurological examination was normal. 
Laboratory tests were normal, including bleeding time 
and coagulation studies. Ophthalmologic evaluation was 
normal. Noninvasive evaluation of the extracranial vas- 
culature included OPG-GEE (oculoplethysmography- 
GEE), which demonstrated a hemodynamically signifi- 
cant stenosis in the left internal carotid artery (ICA). A 
hemodynamically significant lesion in the distal ICA was 
seen with ultrasound spectral analysis. Real-time ultra- 
sound visualized soft plaque at the mid left ICA. 

Because of continued symptoms and agreement be- 
tween two noninvasive modalities about the presence of 
disease in the left ICA, the patient underwent digital 
intra-arterial angiography without incident (Fig. 1). A 
large aneurysm of the distal ICA was demonstrated. 



Approximately five weeks after the initial presentation 
she was operated upon for exploration of the left ICA 
under general anesthesia. A five-minute “test” clamp was 
performed without changes noted on the EEG monitor. 

Figure 1 

Lateral carotid angiogram: There is a large pseudo-aneurysm of the 
distal aspect of the cervical left internal carotid artery, with intimal 
irregularity and/or clot within it. The middle segment is markedly 
narrow and smooth. 

The left ICA was then ligated just distal to the carotid 
bifurcation. Her postoperative course was uneventful, 
and she remains asymptomatic and is not taking anti- 
platelet agents. 


The phenotypic appearance of patients with EDS was 
first described in 1682 by VanMeckern. 3 Ehlers in 1901 4 
and Danlos in 1908 5 further refined his description and 
made note of the three classic features (skin hyperelastic- 
ity, skin fragility, and joint hyperextensibility) of the 
syndrome which now bears both of their names. It has 
subsequently been determined that several genetically 
distinct conditions result in this clinical syndrome, some 
inherited as autosomal dominant, some autosomal re- 
cessive, and one X-linked. 1 The phenotypic expressions 
of this disorder of collagen metabolism include the three 
classic features noted above and may also include “ciga- 
rette paper-thin” scars, multiple ecchymoses, subcutane- 
ous pseudotumors, and life-threatening abnormalities of 
the cardiovascular system. 

In only four of the eleven types of EDS has the actual 
biochemical defect been elucidated. 1 Type IV is the rarest 
and perhaps the most severe form of EDS and may be 
inherited as an autosomal recessive or dominant. The 
underlying abnormality in Type IV EDS is a defect in the 
synthesis, assembly, or secretion of Type III collagen. 6 
The structural integrity of arteries and veins and of 
hollow viscera depends on the presence of Type III 
collagen and is therefore lost in EDS because this type of 
collagen is absent or present in reduced amounts. 7 Pre- 
sumably this is the pathophysiologic basis for vessel wall 
dissection, aneurysm formation, and rupture. Bleeding is 

a common problem in patients with EDS and can be 
life-threatening despite normal platelet function and 
number as well as normal levels of coagulation factors. 
Type III collagen is the predominant form of collagen in 
the subendothelial level of blood vessels and is important 
in promoting platelet aggregation. 8 Poor hemostasis and 
possibly vessel rupture may result from the inability of 
the defective collagen to promote platelet interaction 
with the vascular endothelium. For this reason, DDA VP 
(l-desamino-8-D-arginine vasopressin) had been given 
to our patient during her cesarean section in an effort to 
promote this interaction. 2 

There have been a number of reports of unusual, 
complex, and often fatal vascular disorders in patients 
with Type IV EDS, which has been referred to in the past 
as the arterial or ecchymotic type. Of note is that many 
patients with Type IV EDS have few of the outward 
phenotypic expressions of the disease because of limited 
skin and joint involvement. The first report of a fatal 
vascular complication of EDS appeared in I960. 9 Imahori 
et al reported the first association of multiple congenital 
aneurysms and EDS in a 42-year-old patient, who died 
as a result of intra-abdominal hemorrhage. 10 Pathologi- 
cal evaluation of this patient at autopsy revealed abnor- 
mal appearing collagen fibers in the media of medium 
size (muscular) arteries. Other reports of arterial pathol- 
ogy in EDS describe an irregular thinning of the media of 
large arteries with an obliteration of the internal elastic 
lamina, 11 as well as a separation of the elastic lamina in 
the inner third of the media with increased proteogly- 
cans. 12 There have been numerous vascular lesions re- 
ported in patients with Type IV EDS. These include: 
dissection of the thoracic aorta, aneurysms of the 
abdominal aorta, hepatic, renal, subclavian, splenic, 
and iliac arteries, rupture of the aorta, subclavian artery, 
and the hepatic artery within the liver, as well as varicose 
veins. 1 1,12,13,14,15,16 Arteries are often of normal size and 
do not have to be aneurysmal prior to rupture. 

Cerebrovascular complications of EDS are well 
known. There have been several reports of carotid- 
cavernous fistulas in the literature. 17 > 18 Intracranial aneu- 
rysms have been described as well. 19 We believe this is the 
first well-documented case of an aneurysm of the cervical 
segment of the ICA in the setting of Type IV EDS. 
Because the lesion extended to the bony canal of the 
skull, it was felt that a repair or excision in the usual 
fashion could not be done. Proximal ICA ligation was 
done, and this has been a common procedure for intra- 
cranial pathology in EDS. Ligation was undertaken in 
an effort to treat her frequent episodes of amaurosis 
fugax, as well as to try to prevent rupture of the aneurysm. 

A variety of technical recommendations have been 
made by surgeons and radiologists with experience in 
managing the arterial complications of EDS. Angio- 
graphy can be dangerous in patients with EDS and has 
been associated with vessel wall dissection, perforation, 
and death. Invasive diagnostic procedures should be 

VOLUME 53, NO. 3 


done only when all available noninvasive techniques 
have been truly exhausted. Intravenous digital technique 
may be the safest and most efficient way to assess arterial 
pathology in EDS. Aortic rupture in most cases will be a 
lethal event; however, patients presenting with cardio- 
vascular collapse and acute abdominal pain should be 
explored because of the possibility of branch disruption 
(ie, splenic or iliac), which may be controlled with liga- 
tion. The simple application of ligatures may be difficult, 
and as noted by Barabas, direct suturing may not be 
possible. 20 False aneurysms of the extremities have been 
controlled with ligation. 21 The use of native vein for 
bypass should probably be discouraged because of the 
tendency to varicose vein formation. Hematoma forma- 
tion in the wound is common. 13 


1. Tsipouras P, Byers PH, Schwartz RC, et al: Ehlers-Danlos syn- 
drome Type IV: cosegregation of the phenotype to A COL3A1 
allele of Type III procollagen. Hum Genet 1986;74:41-46. 

2. Weinbaum PJ, Cassidy SB, Campbell WA, et al: Pregnancy man- 
agement and successful outcome of Ehlers-Danlos syndrome Type 
IV. Am J Perinatol 1987;4(2): 134-37. 

3. McKusick VA: Editorial: Multiple forms of the Ehlers-Danlos 
syndrome. Arch Surg 1974;109:475-76. 

4. Ehlers E: Cutis laxa Neigung zu haemorrhagien in der Haut, 
Lockerungmehrerer Artikulationen. Dermatol Ztschr 1901;8:173-74. 

5. Danlos M: Un cas de cutis laxa avec tumeurs par contusion 
chronique des condes et des genoux (xanthome juvenile pseudo- 
diabetique de M.M. Hallopeault Mace de Lepinay). Bull Soc 
Franc Dermatol Syph 1908; 19:70. 

6. Pope FM, Martin GR, Lichtenstein JR, et al: Patients with Ehlers- 
Danlos syndrome Type IV lack Type III collagen. Proc Natl Acad 
Sci USA 1975;72:1314-16. 

7. Byers PH, Holbrook RA, McGilliviay B, MacLeod PM, Lowry 
RB: Clinical and ultrastructure heterogeneity of Type IV Ehlers- 

Danlos syndrome. Hum Genet 1979;47:141-50. 

8. Balleisen L, Gay S, Marx R, Kuhn K: Comparitive investigation ! 
on the influence of human bovine collagen Types I, II and III on 
the aggregation of human platelets. Klin Wochenschr 1975; 

9. Mories A: Ehlers-Danlos syndrome with report of a fatal case. 
Scott Med J 1960;5:269-72. 

10. Imahori S, Bannerman RM, Graf CJ, Brennan JC. Ehlers-Danlos 
syndrome with multiple arterial lesions. Am J Med 1969;47:967-77. 

11. Umlas J: Spontaneous rupture of the subclavian artery in the 
Ehlers-Danlos syndrome. Hum Pathol 1972;3(1): 121-26. 

1 2. Scully RE: Case records of the Massachusetts General Hospital. N 
Engl J Med 1979;300(3): 1 29-35. 

13. Beighton P, Horan FT: Surgical aspects of the Ehlers-Danlos 
syndrome. A survey of 100 cases. Br J Surg 1969;56:255-259. 

14. Burnett HF, Bledsoe JH, Char C, Doyne-Williams G: Abdominal 
aortic aneurysmectomy in a 17-year-old patient with Ehlers-Danlos 
syndrome: case report and review of the literature. Surgery 1973; 
74(4):6 17-20. 

15. Hunter GC, Malone JM, Moore WS, Misiorowski RL, Chvapil 
M: Vascular manifestations in patients with Ehlers-Danlos syn- 
drome. Arch Surg 1982; 1 17:495-98. 

16. Haynes CD, Smith RB III, Dempsey RL, Darden WA Jr: Multi- 
ple congenital aneurysms associated with spontaneous vascular 
rupture. Surgery 1982; 910-12. 

17. Schoolman A, Kepes JJ: Bilateral spontaneous carotid cavernous 
fistulae in Ehlers-Danlos syndrome. Case report. J Neurosurg 

18. Lach B, Nair SG, Russell NA, Benoit BG: Spontaneous carotid- 
cavernous fistula and multiple arterial dissections in Type IV 
Ehlers-Danlos syndrome. Case report . J Neurosurg 1987;66:462-67. 

19. Rubinstein MK, Cohen NH: Ehlers-Danlos syndrome associated 
with multiple intracranial aneurysms. Neurology 1964;14:125-32. 

20. Barabas AP: Vascular complications in the Ehlers-Danlos syn- 
drome. J Cardiovasc Surg 1972;13:160-67. 

21. Wright CB,Lamberth WC, Ponseti IV, Hanson F: Successful 
management of popliteal arterial disruption in Ehlers-Danlos syn- 
drome. Surgery 1979;85:708-12. 


MAY 10, 11, 1989 





The Epidemic Hysteria Dilemma 


O UTBREAKS of illness among schoolchildren can 
be dramatic and perplexing events for school offi- 
cials, physicians, and public health professionals. Such 
outbreaks can pose pitfalls for their investigators, espe- 
cially when the diagnosis of epidemic hysteria is consid- 
ered. In 1986, we were asked to investigate an outbreak 
of possible foodborne illness in sixth-grade students at a 
school in Connecticut. The outbreak occurred while the 
students were practicing the school song for graduation 
ceremonies. At least 39 of the 72 students became ill over 
a half-hour period. Symptoms most frequently reported 
were abdominal pain (74%), headache (67%), sweating 
(64%), weakness (62%), and dizziness (54%). The physical 
examination findings were normal and symptoms re- 
solved for most within three hours of illness onset. Three 
teachers who had eaten food served at the party became 
nauseated later in the afternoon. Further questioning 
suggested that their illnesses may have been associated 
with the perception of having been exposed. The epide- 
miologic investigation revealed that students who had 
eaten chocolate cake at the graduation day lunch were 
more likely to become ill than students who did not 
(relative risk = 2.0, 95% confidence limits = 1 .3 to 3.0, P< 

\ .01). The review of food-handling procedures and labora- 
tory tests of the cake and other foods failed to identify 
problems with preparation or a bacterial or chemical 
cause of illness: 

The rapid onset of illness and resolution of symptoms 
and the absence of vomiting and diarrhea made it diffi- 
cult to attribute this outbreak to a known bacterial or 
toxic cause of food poisoning. Still, we felt an obligation 
to rule out possible physical causes of the outbreak. 
Because the outbreak had some of the features of mass 
psychogenic illness, our “in-house” assessment was that 
much of the illness may have been due to epidemic 
hysteria. 1 Of particular importance was the lack of evi- 
dence of a continuing or more widespread threat to 
public health. This was the key message that we wanted 
to convey to the public. 

The press reported that we were considering the diag- 
nosis of epidemic hysteria on the same day that students 
were given the food history questionnaires. Our unantic- 

HAROLD BURDO, MPH, Department of Health Services, State of 
Connecticut, 150 Washington St., Hartford, CT 06106. 

Reprinted with permission from American Journal of Diseases of 
Children, March 1989. 

ipated public discussion of this diagnosis was done large- 
ly without the results of the data analysis, which was 
completed a week after the outbreak. Despite our assur- 
ances that the symptoms of psychogenic illness were real, 
some parents insisted that we had accused their children 
of faking symptoms and that a “stigma” had been put on 
their children. Levine 2 has suggested that the treatment 
of mass hysteria should include informing patients and 
the public of the suspected psychological cause of the 
illness. Our experience suggests that with such notifica- 
tion, the diagnosis can become part of the problem and 
the public relations aspect of an investigation can easily 
become the primary focus of activity. 

Differentiating a foodborne outbreak from epidemic 
hysteria has important implications for clinical treat- 
ment and for public health control measures. If done 
early enough, an epidemiologic investigation can help 
focus control measures, especially during a foodborne 
outbreak. If done after an outbreak is over, an epidemio- 
logic investigation can help in the review of professional 
decisions. Our investigation revealed an association 
between eating chocolate cake and illness, an association 
that we found difficult to explain and that was for us 
analogous to finding an unexpected cause of death at 

Some authors have cautioned against extensive epi- 
demiologic investigations when epidemic hysteria is con- 
sidered because of the tendency of such investigations to 
prolong public concern. 1 ’ 3 Clearly, the public relations 
aspect of the investigation must be handled carefully to 
avoid public misunderstanding. In retrospect, psychiat- 
ric consultation might have been helpful in managing the 
outbreak, both to examine children for positive psycho- 
logic data and to endorse the diagnosis of epidemic 
hysteria. Outbreaks similar to the one that we investi- 
gated happen often enough that clinicians and public 
health professionals need to become better acquainted 
with the science and art of dealing with epidemic hyste- 
ria. It is hoped that knowledge and experience once 
shared will lead to better ways of managing such episodes. 


1. Small EW, Borus JR: Outbreak of illness in a school chorus: Toxic 
poisoning or mass hysteria? N Engl J Med 1982;308:632-5. 

2. Levine RJ: Mass hysteria: Diagnosis and treatment in the emer- 
gency room, editorial. Arch Intern Med 1984;144:1944-5. 

3. Epidemic hysteria, editorial. Br Med J 1979;2:408. 

VOLUME 53, NO. 3 







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Legal Aspects of Employing “Counselors” in a Clinical Practice 


ABSTRACT —With the increasing reliance of the medi- 
cal profession upon nonlicensed counselors as employees 
or associates for facilitating psychosocial, rehabilitative, 
and various other services or guidance to patients, there 
is a parallel increase in liability exposure. Even if the 
counselor is not directly employed by the professional, so 
that the tort doctrine of respondeat superior would not 
pertain, other ties could cause either a direct agency or an 
ostensible agency doctrine to attach. This is so even if a 
referred patient merely had reasonable cause to (mis)un- 
derstand an apparent agency relationship. Billing must 
be precisely worded and coded. There are ethical, medi- 
cal, and legal responsibilities to screen applicants and to 
monitor, formally supervise, and record a counselor’s 
work. Standards of care are unclear or untested. Referral 
of a troubled patient to an uncredentialed assistant may 
convey trivialization to the patient; however, beware 
misrepresentation of expertise. Failure to diagnose under- 
lying disorder is a risk. Protocol agreement defining the 
scope of the relationship and the scope of practice may 
help limit liability. Any economic arrangement or pre- 
scription of a particular counselor’s services can lead to 
the doctor’s being joined in a suit, especially because of 
the “deep pocket” theory. Clarification of liability cover- 
age is therefore prudent. 

T HERE is a trend in medical, psychiatric, and clinical 
psychology practice toward increasing reliance on 
nonlicensed staff for the counseling of patients for men- 
tal health, family or school problems, nutritional needs, 
or exercise and rehabilitation, and so forth. Where the 
licensed professional shares, refers, or supervises cases 
with nonlicensed counselors (used as a generic), such 
collegial or employing physician or clinical psychologist 
has a number of duties, obligations, and liabilities to 
these patients that are more complex than they seem to 
many practitioners. Delegation to unlicensed agents pre- 
sents a threat to the caliber of service offered, and if 

ROBERT S. WALZER, M.D., J.D., is a medical-legal consultant 
in private practice. The basic research for this article was done while the 
author was a law intern in the Medical Quality Assurance Section, 
Hearings Office, Connecticut Department of Health Services. 

Reprint requests to: 26 Beeholm Rd., West Redding, CT 06896 (Dr. 

unsupervised and unregulated, it can undo the protec- 
tions provided the public by requirement of licensure. 
Cases of such failure injurious to patients have appeared 
at the regulatory agencies. In addition, some clinicians 
and provider entities rent office space to, and / or form an 
actual or seeming (apparent or ostensible) relationship 
with, a “counselor” who is not governed by membership 
in, or by the standards of, a licensed profession. Tort law 
doctrines of vicarious liability are, today in this litigious 
world, understood by most clinicians. However, statutes 
and regulations often come to bear, and the latter are 
frequently scattered, not easily located, and not com- 
monly known even within the legal profession. There are 
also a number of not sufficiently well known professional 
and ethical standards issued by societies and organiza- 
tions that could certainly be introduced in litigation by a 
well-prepared attorney seeking to define a standard of 
care. (These will be discussed in detail in a subsequent 
article on mental health-care entities.) 

The most common reason for which the licensing 
board becomes involved is related to questions over 
third-party billing by the professional for such counsel- 
ing actually rendered by an employee or supervisee. But 
the billing issue acts as a gateway to many other ques- 
tions of liability that could support a possible cause of 
action where a patient or counselee claims injury caused 
by allegedly negligent care. 

Case example: A physician referred a child with school 
problems to the counselor whom he employed for such 
purposes. The employee had professional training but 
had chosen not to seek a license. Billing was done by the 
physician on his letterhead, the charge simply attributed 
to “visit” or “counseling.” After a number of twice- 
weekly, and later weekly visits, the third-party payor 
refused further payments on the ground of noncovered 
service, and asked that the physician be more specific as 
to the service given: definition, identity of the person 
actually doing the counseling, and a diagnosis for which 
it was rendered. The patient’s parents sent an inquiry and 
complaint alleging unethical and substandard treatment 
to the Department of Health Services, and an investiga- 
tor found insufficient supervision of the counselor, insuf- 
ficient feedback to the doctor by the counselor, and 

VOLUME 53, NO. 3 


unclear if not evasive billing. Ultimately, a case was 
opened that covered these issues as well as questions of 
the referral pattern between the two professionals, their 
economic arrangements, supervisory and diagnostic pro- 
cedures in this and all other cases shared by the two, and 
ongoing medical observation of a shared patient who is 
taking medication and / or has a physical illness. The case 
was settled between the physician and the Department 
with an agreement for compliance with terms and guide- 
lines that are discussed below. 


Billing practices involve matters of ethics, regulations, 
policy, and third-party payor requirements. Concisely, 
these add up to the following: a licensed physician billing 
in his or her name for medical services must personally 
have provided them, unless the services were performed 
by a nonlicensed delegate “directly controlled by” the 
physician, in the physician’s presence, for a relatively 
minor or delegable procedure. 1 The “presence” of the 
physician may be somewhat broadly defined within 
standards of good care, and thus it does not necessarily 
mean that the physician must be in the same room or 
observing the activity, but, at least according to regula- 
tions (noted below) of the Department of Income Main- 
tenance (DIM), within five to 15 minutes away. It is 
generally agreed that counseling is not a relatively minor 
procedure. Therefore, the delegated counseling should 
be so described on bills for services on the physician’s 
letterhead, with the name of the counselor and the 
number and duration of visits specified. Omission of 
these data regarding the counselor’s role in services billed 
by the professional is considered erroneous or evasive, 
and might imply fraud or misrepresentation to the billed 
party. 2 * 3 An essentially identical statutory provision ap- 
plies as well to psychologists in Connecticut. 4 The Board 
of Examiners of Psychologists has ruled the above provi- 
sions applicable to clinical psychology, and further ruled 
that the name of the delegated assistant must appear in 
any bill or “listing of services performed. . . .” 5 Aetna, it 
may be noted, does not hold these forms of mental health 
counseling as exclusively or particularly medical and 
Aetna would not reimburse for these, as of April 1988, 
but The Hartford would cover “medical” counseling. 
Medicare would “downcode” if uncertain. 

While a licensing board or department does not moni- 
tor the licensed professions for the protection of insurers, 
questions of misrepresentation, lying and fraud, moral 
turpitude, and unethical conduct inconsistent with the 
practice of medicine or psychology are within the juris- 
diction of the medical quality assurance divisions of the 
departments, and they may investigate and prosecute. In 
a case involving a psychiatrist who employed a licensed 
psychologist and a number of nonlicensed counselors 
but who billed all patients alike as having psychotherapy 
at private psychiatrist rates, the DIM ruled that the 
practice was run as a clinic and should bill at clinic rates. 
The investigation had found that the psychiatrist had 

never seen many of the patients who had come to his 
practice and who were seeing counselors exclusively; 
further, the charts showed no evidence of psychiatric 
supervision or control. The ruling noted that a licensed, 
employed psychologist did not require the amount of 
supervision that the unlicensed personnel should be 
given. The psychiatrist was fined and required to reim- 
burse Medicaid for overpayments. 6 Medical services of a 
physician may include assistance for the doctor, but this 
must be under the doctor’s “personal supervision,” and 
the physician must actually see the patient and have 
actually performed an examination and rendered a diag- 
nosis; furthermore, “[t]he physician must be on the prem- 
ises at all times and immediately available, meaning 
within five minutes.” 7 

The DIM, under Medical Services Policy Regulation 
183 I. III. a.-c., provides payment for a psychologist’s 
services only if those services were rendered personally 
by the psychologist. 

It should be remembered that an exclusive referral 
pattern is unethical and suggests negligence in proper 
referral care. 

Fee-splitting is also unethical, and “rent” paid by a 
counselor that is derived from a percentage of fees gener- 
ated by the referrals is splitting. An hourly rent, however, 
may escape this categorization, but it would be advisable 
to obtain a ruling on this from the appropriate depart- 
ment and professional association for the particular 

Supervision of a Counselor Whether or Not an Employee 

A physician or psychologist is expected to oversee, 
train, and supervise his or her staff, and to function 
under and within the laws and ethics that govern. It is 
improper and unreasonable to expect any greater profes- 
sional capabilities of staff than can be expected by virtue 
of education, training, and experience. 

But what is “supervision?” What would it mean as the 
basis for a reasonable and prudent standard of care 
under the law? In everyday practice, one might be able to 
“oversee” in a rather cursory or unstructured style that 
has no formalized routine. However, supervision of an 
assistant is generally understood to be a more formalized 
activity and process than mere oversight; the assistant’s 
work must be “under the physician’s supervision and 
control,” with the doctor overseeing and participating in 
the assistant’s work, and with review on a “regularly 
scheduled basis.” 8 We come to realize and recognize that 
cases under the attention of the counselor need to be 
discussed and direction to be given as medically indi- 
cated, and that some sit-down discussion between the 
licensed, responsible professional and the employed or 
otherwise associated counselor is a reasonable expecta- 

Guidelines do not seem to exist regarding the amount 
of time to be given to supervisory discussion of a case in 
these circumstances any more than the time to be given 



to patient visits, but diligent and prudent care and atten- 
tion to the patient’s needs, and thus to the work of the 
counselor, are reasonable expectations. This also sub- 
sumes adequate communication by the clinician to the 
counselor of pertinent medical and social circumstances, 
in order for the counselor to carry out his or her role 
safely and effectively, and with due regard for the counse- 
lee’s health and abilities. 

The legal standard applied to the professional is that 
of the reasonable, prudent physician or psychologist; a 
specialist would be held to standards for the specialty. 
Thus, a psychiatrist or psychologist would likely be held 
to stricter standards regarding supervision than others 
because supervision has always played a key role in their 
professions and in casework as well. 

While feed-back of information from the counselor to 
the professional may occur during such supervisory dis- 
cussion, important material that may be relevant to the 
patient-counselee’s medical or general care or prognosis 
should be communicated and documented contempo- 
raneously. Supervision should not be preempted by mere 
nonsupervisory reportorial communication. For legisla- 
tive intent here, recall the Conn. Gen. Stat. §20- 12a 
requirement of supervision of a physician’s assistant 
including “regularly scheduled” review of the assistant’s 
practice and the physician’s “continuous availabil- 
ity” even through “radio, telephone or telecommunica- 
tions. . . .” The physician/ counselor relationship would 
likely be held to at least the same standard. 

In fact, the physician or psychologist is advised to have 
a formal supervisory protocol for regularly guiding and 
overseeing the work of the counselor (who is his or her 
agent) and to assess for possible inadequacy of care (for 
instance, development of problems beyond the scope of 
the counselor’s expertise or even the physician’s or psy- 
chologist’s expertise, raising the indication for referral to 
a more appropriate treatment). While such a protocol 
will serve to help the parties to accept the importance of 
and to institutionalize the activity, it also documents the 
participants’ recognition of its place in the conscientious 
care that they provide. 

Through a “scope of practice” agreement with the 
counselor the professional might attempt to contain the 
area of risk exposure. This protocol would define the 
work, duties, and objectives of the counselor as accepted 
and approved by the physician. While this definition 
may be less tenable or defensible than for a licensed nurse 
or other professional employee, and even for a certified 
and statutorily defined (but not licensed) physician assis- 
tant, it would possibly offer some protection from allega- 
tion of injury attributed to treatment that exceeded the 
limits of the protocol. 

Vicarious Liability 

The physician or licensed professional has continuing 
responsibility for the quality of care rendered to patients 
by the counselor. In a sense, the professional is treating 

the counselee through the agency of the counselor; this 
doctrine is true for the psychiatrist or psychologist, long 
accustomed to working with or in the role of a supervi- 
sor, but it is no less true for the obstetrician or nephrolo- 
gist who works with (or through) a counselor (or agent). 
Under tort law, the employer is responsible for the injur- 
ies caused by negligence of an employee acting within the 
scope of her duties. Moreover, a doctor could be held 
liable for negligent conduct of an employee or associate if 
the injured party had reasonably believed, or been in- 
duced to believe, that the doctor had been in control of 
the conduct of the employee or associate: this is called the 
doctrine of ostensible or apparent agency. 9 The unli- 
censed counselor-employee cannot act independently, 
unlike a licensed nurse in some circumstances. Because 
the doctor represents a richer lode than a nonprofes- 
sional assistant, patients alleging harm by the latter will 
seek to target the “deeper pocket” in litigation. 

Misdiagnosis of and/or failure to treat an underlying 
affective disorder, suicidal potential, or physical disease 
through inadequate history-taking or diagnostic inept- 
ness would be the likely sources of litigation. If sufficient 
progress is not made within a reasonable period of coun- 
seling, the professional should review the case and con- 
sider referral to a specialist, and discuss alternative care 
with the counselee, to avoid prolongation of psychic 

Where a patient with the expectation of standard 
medical care comes to a physician’s office complaining of 
“bulimia,” for instance, should the receptionist route the 
patient to the nonlicensed counselor who was trained in 
pastoral counseling and is employed by the doctor, and 
the patient never to see the physician? Not only may this 
be misleading to the patient, but the physician is being 
negligent. Both the patient’s well being and the physi- 
cian’s license would be in jeopardy. 

Quality Assurance, Records, and Documentation 

It is prudent (it is actually a legal duty) to check the 
credentials and references of the counselor to be em- 
ployed, to communicate with prior employers, and to be 
alert to indications of possible substance abuse. These 
are all the more critical because nonlicensed counselors 
are not monitored by licensing agencies, obviously, and 
may not belong to any professional societies; therefore, 
these cannot provide a file review for complaints. 

The counselor-employee should regularly enter notes 
into the patient’s charts or records, and the physician’s 
entries should indicate that he or she is aware of these 
notes and the patient-counselee’s status. The counselor 
should also keep more detailed records or process notes, 
especially those too confidential or irrelevant for the 
medical chart, but reviewable in supervisory discussion. 

Incidentally, in some jurisdictions, mental health re- 
cords or communications to a generic psychotherapist 
enjoy a privileged and confidential status that medical 
records do not, at least if the counselor fits the statutory 

VOLUME 53, NO. 3 


definition of psychotherapist, psychologist, or psychia- 
trist. Connecticut’s statutes convey this privilege exclu- 
sively to patient communications to psychologists and 
psychiatrists. 10 Remember that a physician-patient privi- 
lege does not exist at common law and has not been 
legislated in Connecticut and many other states. In Con- 
necticut, while statute and psychiatric authorities hold 
that only a licensed psychiatrist provides psychiatric 
treatment 'f 12 and Conn. Gen. Stat. §20- 187a reserves 
psychological services to licensed psychologists, other 
professions lay claim to psychotherapy , arguing that it 
can be provided by an array of therapists and counselors. 
However, the Connecticut Board of Examiners of Psy- 
chologists and the Connecticut Attorney General, in 
their statements cited above, are of the opinion that only 
licensed professionals can perform “psychotherapy.” The 
Uniform Rules of Evidence, procedural rules of court 
governing the production of evidence and adapted for 
use in a number of state court systems, require, in Rule 
503, that a “psychotherapist,” for the sake of privileged 
communications, be either a licensed physician or psy- 
chologist, but confidentiality is extended to communica- 
tions made for purposes of diagnosis or treatment to 
“persons” participating in the process under the direction 
of the physician or psychologist. Therefore, it is arguable 
in some jurisdictions and certain in others that commun- 
ication to a nonlicensed counselor is not protected by 
statutory privilege, especially if required supervision, 
direction, and control are not provided. Should, at least, 
certain patients who may possibly and reasonably be 
relying on it be timely informed of the possible lack of 
such privilege? 

Of course, there is a duty to not treat, directly or 
through an agent, illness or disorder which is not encom- 
passed by the education, skill, or training of the clinician 
or the agent, with the possible exception of stop-gap 
emergency care. It is advisable that patients with possible 
or actual active or on-going organic mental disorders, 
major depression, or suicidal or assaultive potential be 
referred to the most appropriate professional diagnostic 
and treatment resource. Thus there is a duty first to 
evaluate and diagnose every patient prior to referral to 
the counselor, and to rule out underlying medical disease 
and disorder beyond the expertise of the clinician or 
counselor. A pediatrician’s specialty would reasonably 
include nutritional and dietary expertise, and a nonli- 
censed nutritionist’s counsel could be a service delegated 
by the doctor under his or her direct supervision and 
control. In this era of psychopharmacotherapy and com- 
plex testing for affective and other psychiatric disorders 
and their consequences, it could be questioned whether 
the pediatrician could provide adequate supervision of a 
mental health “therapist’s work. . . .” 13 

The public is free to seek counseling or treatment from 
unlicensed providers. The Department of Health Ser- 
vices, which regulates licensed health-care providers, would 
not have jurisdiction, and statutes and regulations regard- 

ing the professional conduct of licensed individuals and 
entities would not pertain. If a question arose as to 
quality of care, the client would have to turn elsewhere in 
the law. But when a licensed physician, psychologist, or 
clinic is the employer of such nonlicensed staff, the 
license holder, under the law, directs the treatment and is 
expected to conform to the letter and intent of the law. 

Promises, Implied Promises, and Misrepresentation 

A physician’s assistant may be trained for certain 
procedures and responsibilities, which presumably may 
include counseling. The physician or psychologist has a 
duty not to misrepresent services provided and not to 
hold out as being rendered services not in fact provided. 
It is wise to avoid even misleading vocabulary or the 
suggestion that the patient being referred to the counse- 
lor or assistant is to receive the same or the equivalent of 
treatment that would be rendered by a more trained or 
certified professional such as a licensed therapist, physi- 
cian, or clinical psychologist. The author has heard 
countless examples of referrals to an employed or asso- 
ciated counselor with words such as, “Mrs. X will help 
you in half the time and a tenth of the cost that the 
psychiatrist would run up,” or, “Mr. Y will get you better 
fast, without pills; and if you do need pills, I can prescribe 
them, so you don’t have to go to a shrink.” These asser- 
tions may be essentially true, but they also suggest to the 
patient that the physician and the assistant or associate 
are offering not only the same result but the specialist’s 
expertise in psychiatric diagnosis and treatment. 

“The counseling [by the nonlicensed employee-coun- 
selor] shall be for those personal or family problems that 
the physician [himself or] herself would be competent to 
counsel directly had [he or] she not delegated such duties 
to the counselor.” 14 Similarly, such referral by a clinical 
psychologist should be for personal or family problems 
of a degree that does not warrant or require, by ordinary 
or prevailing standards of care within the field of clinical 
psychology, the full care of and treatment by a clinical 
psychologist or other appropriate licensed health profes- 

Informed Consent 

While not a statutory requirement, it is prudent that 
referral to the clinician’s employee for counseling be 
defensively considered prescription of a procedure war- 
ranting the informed consent of the patient. The patient 
should be told the purpose and aim of the referral, that 
the particular counselor is not a licensed professional but 
is considered competent to provide assistance in obtain- 
ing a desired objective, that a licensed professional may 
alternatively be consulted for counseling or a second 
opinion. Full discussion should be provided so that the 
patient may make an informed decision. Caution would 
dictate that patients or clients should understand the 
extent of the physician’s involvement in the treatment 
process, and comprehensive documentation of informed 
consents and supervisory or other contacts should be 




If the counselor is not an employee or otherwise asso- 
ciated except through the rental of space on the premises, 
it is appropriately defensive for the professional to dis- 
close these circumstances, and to require the counselor to 
make this clear to clients derived from extrinsic sources. 
Neither the counselor’s nor the physician’s letterheads 
should bear the name of the other where they are inde- 
pendent practitioners. Whereas the patient should reas- 
suringly be informed that the physician or psychologist 
bears continuing responsibility where this is so, the 
patient should be informed that the independent profes- 
sional does not carry the burden of responsibility for 
treatment by the counselor who is a mere tenant offering 
independent services . 15 


Thus, whatever the motivation may be for provision 
of or affiliation with a nonlicensed counselor in the 
private practice of medicine, because the physician re- 
presents the “deeper pocket,” the legal and, therefore, 
economic pitfalls run far and deep. On balance, it is 
easier to screen, more sound to rely upon, more respect- 
ful of patients’ trust, and more clear to defend in court 
the conduct of a credentialed counselor. Through his or 
her employees and collegial relationships, the licensed 
professional places his or her liability and license on the 
line. If adequate supervision, direction, and control can- 
not be provided, a physician should not employ a nonli- 
censed counselor nor bill for his or her services. Since no 
procedure is totally secure, and licensed personnel may 
not be available, or the services of nonlicensed staff may 
be necessary, reference to these guidelines and consulta- 
tion with counsel and/or insurer are advised. 


1. Conn. Gen. Stat. §20- 12a (1987) - Physician Assistant’s services 
and supervision enumerated. 

2. Conn. Gen. Stat. §20- 13c (14) (1987) - illegal, incompetent or 
negligent conduct in the practice of medicine. 

3. Conn. Gen. Stat. §20-45 (1987) - disciplinary action - physicians. 

4. Conn. Gen. Stat. §20- 192 (1987) -disciplinary action -psychologists. 

5. Conn. Board of Examiners of Psychologists, declaratory ruling, 28 
January 1985. 

6. State of Connecticut Department of Income Maintenance, For- 
mal Hearing, 20 May 1981. 

7. Department of Income Maintenance Regulations, Medical Ser- 
vices Policy, Physicians’ Services 177B.II (1987). 

8. State of Connecticut Attorney General Staff Opinion, 18 October, 

9. Firman GJ, Ostensible agency: another malpractice hazard, Am J 
Psychiatry, 1988:145:510-12. 

10. Conn. Gen. Stat. §52-146(c) (1987) -Communication to a psychol- 
ogist is privileged; §52-146(d) - psychiatrist. 

1 1 . Connecticut Psychiatric Society letter from President T. Zanker to 
G. Tischler, Chair, Department of Psychiatry, Yale University, 7 
May 1987 - discussing Department of Mental Health draft, infra. 

1 2. State of Connecticut Department of Mental Health, Draft: Outpa- 
tient Clinic Program Standards, 9 February 1987. 

13. State of Connecticut Department of Health Services, Medical 
Quality Assurance, attorney (Mandly, G.) staff memo, 8 January 
1987, p. 7. 

14. State of Connecticut Department of Health Services, Medical 
Quality Assurance, staff opinion letter, 9 January 1987. 

15. See, Firman GJ, n. 6. 

The author wishes especially to thank Stephen Harri- 
man, Chief, Bureau of Health System Regulation, Stan- 
ley Peck, J.D., David Pavis, J.D., and John Daly, J.D., 
for extending the privilege, trust, and encouragement to 
work and study in their departments, and to thank Ann, 
Eric, and Steven for their support and tolerance. 

VOLUME 53, NO. 3 


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Old Age and New Policy 


I N the fall of 1987, the Reagan administration an- 
nounced a 35.8% increase in the monthly Medicare 
Part B premium for 1988. This increase, from $17.90 to 
$22.80, was the largest annual rise in the history of the 
program. An increase of that size would have been 
expected to draw an instant protest. However, while 
there were groans from the elderly and others, it was as if 
a new realism had set in that protest would, in any case, 
do little good. 

The simple truth is that health care for the elderly is 
expensive, that it will become even more so in the years 
ahead, and that no quick solution is at hand. Expendi- 
tures for the elderly under the Medicare program have 
increased at an inflationary rate of approximately 8% for 
the past few years; this is a rate twice the general pace of 
inflation. Despite almost two decades of trying, all efforts 
to control these costs have failed, and there is no reason 
to be hopeful about significant success in the future. 

A recent study of the projected costs of the Medicare 
program, for example, presents figures of startling mag- 
nitude. 1 Under what the authors call “intermediate” pro- 
jections, there will be deficits of $27.3 billion by the year 
2000, and $117 billion by 2020. Those are the optimistic 
figures. Under more pessimistic but not improbable pro- 
jections, the deficit will be $62.5 billion by the year 2000 
and $210 billion by 2020. This means, the authors say, 
“that restoration of fiscal equilibrium for Medicare would 
eventually require that either its current projected tax 
burden be more than doubled or its currently projected 
expenditures more than halved.” 1 These figures, more- 
over, are projections from the present Medicare pro- 
grams; they do not include the many new proposals and 
pending bills for long-term and home care. 

In light of these trends, I believe that nothing less than 
a full rethinking of the relationship between health care 
and old age will do. Costs will not be controlled or old 
age made meaningful unless we curb our insatiable appe- 
tite for a longer life regardless of the expense. There are 

DANIEL CALLAHAN, PH.D., Director, The Hastings Center, 
Briarcliff Manor, N.Y. 

Reprinted with permission from JAMA , February 10, 1989, Vol. 
261, No. 6. 

some fundamental but unavoidable choices in thinking 
about health care for the elderly. We can continue along 
the present path, tinkering endlessly with the present 
Medicare system and, as we do now, gradually increas- 
ing the premiums and out-of-pocket expenses for their 
recipients, or we can begin the bolder but now imperative 
task of asking what would be an acceptable and reason- 
able goal for health in old age. We need a more coherent 
and fair system and, to make that work, one that sets 
limits to care, particularly life-extending technological 

But why won’t tinkering work? We have allowed our- 
selves to be beguiled by dreams of greater efficiency. 
However, not one of the much-touted measures intro- 
duced to control costs during the past decade has had 
any noticeable impact. Consider the fate of the most 
prominent of such policies: the diagnosis related group 
system has reduced hospital inpatient costs only to drive 
up outpatient costs and the costs of short-term nursing 
care. The result has been a wash, with no significant 
overall reduction in cost increases. Increased competi- 
tion that was meant to lower costs by giving consumers 
more choices, has, in fact, increased costs by stimulating 
a greater consumer desire for health care and competitive 
efforts to improve services. The health maintenance 
organization movement seems stalled for the time being, 
itself the victim of costs it cannot control. Efforts to use 
corporate economic muscle to extract bargains from 
providers have yet to succeed. In 1989, corporate health 
care costs are expected to increase anywhere from 20% to 

The claim that billions of dollars can be saved if there 
were only greater rationality in the system — fewer unnec- 
essary diagnostic procedures and useless, untested treat- 
ments — is perfectly plausible as an attractive theory, and 
“cutting the fat” is a wonderful slogan. However, possi- 
bility should not be confused with probability, and the 
failure after some 18 years of cost-containment programs 
should give pause to even the most congenitally optimis- 
tic person. 2 

As those efforts to cut the fat have failed in short-term 
care, thousands of elderly persons are forced to forego 

VOLUME 53, NO. 3 


decent long-term or home care — options that are grossly 
underfunded by Medicaid. Many who do receive such 
care do so at the humiliating price of “spending down” 
their life savings and forcing themselves into the impov- 
erishment that qualifies them for Medicaid assistance. 
We can, in short, neither control the costs of service that 
we do provide nor come up with the money for service 
that we do not provide. 

Even in the face of these realities, however, there are 
many who would deny that there is a serious problem. 
We are an affluent country, it is said, and can afford to 
pay whatever good health care requires. In one sense, of 
course, we can: we can simply decide that health care 
expenditures for the elderly are more important than 
education, housing, general welfare, roads, and recrea- 
tional facilities. But would it make sense to run a society 
that way, to let expenditures in one category — even a 
vital one — trump all other categories or to allow the 
needs of the elderly always take precedence over the 
needs of other age groups? Would that be fair? Would 
that be reasonable? I do not see how it could be, but that 
is what it would mean simply to give health care expendi- 
tures for the elderly a privileged position. 

As an increasing number of public opinion surveys 
make clear, moreover, the public wants both more and 
better health care but is unwilling to pay significantly 
higher taxes to get it. As a recent study of public opinion 
by The Public Agenda Foundation concluded: “As con- 
cerned as they were about their vulnerability to the high 
cost of catastrophic insurance and long-term care... most 
of the participants. ..remained unwilling either to lower 
their own expectations about what the government should 
provide, or to pay what is necessary for even a modest 
level of government-provided coverage.... While there is 
strong support for more government involvement in this 
area, there is no corresponding inclination to pay for it.” 3 

However, even if we could or would spend much more 
on health care for the aged, unlimited disproportionate 
growth would not be tolerable, and the logic of modern 
high-technology health care is toward open-ended, un- 
limited expenditures. It envisions no stopping point at 
all. Right now, the very old do not receive a great deal of 
high-technology medicine. However, the trend is clearly 
in that direction, with a constant upward swing in the 
number of treatments and procedures originally devel- 
oped for younger patients being applied to elderly 
patients. Pursuit of that course will not necessarily make 
old age more meaningful and satisfying — many of the 
elderly are already terrorized by the prospect that mod- 
ern medicine will all too effectively keep them alive all to 
long — and it will surely divert money from the health 
and other needs of younger age groups. 

An alternative would be to first recognize the failures 
of the present system. The present Medicare program 
creates a cruel imbalance between support for life-extend- 
ing, high-technology medicine and that medical care 
necessary for a decent quality of life, most notably. 

affordable long-term institutional care and decent home 
care. The success of medicine in saving and extending 
lives has meant a dramatic increase in chronic illness, 
especially for those over the age of 80 years. Our present 
system is utterly inept and insensitive in coping with that 

Over the short run, then — by which I mean the next 
ten to 20 years — we need to work toward righting the 
balance and shifting the emphasis of our entitlement 
programs. We should gradually move from a bias toward 
short-term, critical-care medicine for the elderly to the 
provision of well-funded, long-term and home care and 
all of those other needs of the elderly that improve the 
quality of their day-to-day life, though not necessarily 
extending that life. A longer average life span for the 
elderly will not necessarily be a better life. If a premature 
death has been avoided, there is after that no obvious 
correlation between length of life and human happiness. 
What the elderly want is physical and economic security, 
a sense of meaning and social significance, and the provi- 
sion of care for their mundane needs. This phase of 
shifting emphasis will be one of increased costs, but the 
eventual goal will be to have an entitlement program and 
matching health care system that has a radically different 
set of priorities. 

A second ingredient would be to accept the idea of 
limits on life-extending, high-technology care for the 
elderly. Those like myself who are not yet old, but who 
will be over the next two to three decades, must begin 
rethinking their own expectations about government- 
supported care. We cannot ultimately limit care at the 
frontier of old age on a case-by-case basis or by trying to 
work with the idea of individual need. Individual need in 
the case of the elderly will always be a matter of techno- 
logical possibility and social expectation. People “need” 
what will stave off death and make them well; that is 
what we all desire. Despite its aura of objectivity, there- 
fore, “need” is not a fixed, objective standard at all, nor 
can it ever be. It is culture and technology dependent and 
ever attached to subjective desires. For just those rea- 
sons, it cannot serve as an adequate standard for allocat- 
ing resources. To say that we should use individual need 
as the standard is, in effect, to say that we should leave 
the large, social allocation questions to the individual 
physician at the bedside. However, for many years now, 
we have been hearing correctly, I believe, that rationing 
should not take place at the bedside. 

In any case, unless we believe in an “invisible hand” of 
some kind, there is no reason to believe that what is right 
for each individual will be exactly what we can afford or 
what makes sense for the society as a whole. These are 
the pitfalls of rationing on a case-by-case basis. We need 
a more fair and more uniform standard to make these 
decisions, and I propose that a flat age limitation on the 
most expensive forms of life-extending care would meet 
that standard. 

How would we select an age? I think we now have 



cultural traditions and common expectations that can be 
built upon to fashion such a standard. We can think in 
terms of a “natural life span,” not natural biologically, 
but natural in the sense of our common biographies. By 
their late 70s or early 80s, most people have had a chance 
to do most of what a human life offers — to love, to raise a 
family, to travel, to think, to read, to enjoy nature, and to 
make sense of their lives and destinies. It is not that a 
longer life would not afford more possibilities; of course, 
it would. However, it is not reasonable to expect that a 
public entitlement program should be tailored to our 
individual needs and desires. I might well want to live to 
be 100 or 105 years old, and I might well need an artificial 
heart to help me do so. Yet it would not be reasonable, 
when faced with other social needs, for my neighbor to 
be taxed to pay for my achievement of that goal. I can 
only ask of him that he help me to avoid a premature 
death, to live a reasonably long life, and to make my last 
years as comfortable as possible. That goal is compatible 
with setting a specific age limit, one that we could, as a 
society, collectively decide upon and use as a limitation 
on Medicare coverage (though never to limit the relief of 
pain and suffering). It would not be wholly fair, but then 
there are no ways of setting limits that can be wholly fair. 
In any case, no plausible alternatives have ever been 

But would it not be “ageist,” as some advocates of the 
elderly claim, to use age as a standard to limit life- 
extending care? Not at all, if it was done in the name of 

providing a higher quality of life for the elderly by begin- 
ning a transfer of emphasis from short-term-care medi- 
cine to other forms of care, notably, long-term and home 
care. What is required is a better balance between the 
kinds of care the elderly need. A proper balance — to be 
affordable — would require limits on the life-extending 
care, but the result would be a more full, more coherent 
care program. This approach would not be an assault on 
the dignity of the elderly if viewed with respect for the 
needs of everyone and with a more unified vision of the 
life cycle. At present, the elderly have the privilege of the 
only entitlement program that is not based on need. To 
suggest that what is, in the first place, a very special 
program and admit some ultimate limit is not to deprive 
and denigrate the elderly: it is only to recognize that we 
live in a finite world. 

We do need a new vision of health care for the elderly. 
A medical care system that would give each of us an 
adequate but not indefinitely long lifetime, and that 
accepted death in old age, would be one both more 
humane for the elderly and financially sensible for every- 
one else. Medicine cannot conquer death or old age, but 
it can bankrupt us trying to do so. 


1 . Holanhan J, Palmer JL: Medicare’s Fiscal Problems: An Impera- 
tive for Reform. Washington, DC, The Urban Institute, 1988, p 9. 

2. Schwartz WB: The inevitable failure of cost-containment strate- 
gies. JAMA 1987;257:220-4. 

3. Melville K, Doble J: The Public’s Perspective on Social Welfare 
Reform. New York, The Public Agenda Foundation, 1.988, p 75. 

CSMS Keeps Courtesy Card in Effect for Services 

The Connecticut State Medical Society is aware that the deadline for use of the CSMS Medical Courtesy 
Card passed on December 3 1 , 1988. By this date, it was hoped that all holders of the Courtesy Card would have 
applied for and received a State of Connecticut Medicare Assistance Program (ConnMAP) Card in order to 
continue to receive the benefits of the assignment program. However, because many seniors have not had their 
Courtesy Cards replaced, CSMS is urging member physicians throughout the state to continue to honor the 
Courtesy Card for seniors who have not yet received their new state cards and to advise their senior patients who 
have not yet applied for the ConnMAP card to contact the^fate Department on Aging immediately. 

For anyone interested in obtaining information concerning the ConnMAP program, contact the Department 
on Aging at 1-800-634-8852, or write ConnMAP, P.O. Box 6886, Hartford, CT 06106. 

VOLUME 53, NO. 3 


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Options to Control the Rising Health Care Costs 

of Older Americans 


W ILL our economy be able to withstand the in- 
creasing health care costs of older Americans? 
These per capita costs increase as a function of the age of 
our adult population and escalate rapidly in the last years 
of life. For example, the average Medicare reimburse- 
ment per person for those aged 65 to 66 years is $1239 
compared with an average cost of $2583 for those aged 
85 years and older. 1 The future growth of the population 
of those aged 85 years and over, a group frequently 
referred to as the “oldest old,” will have a substantial 
impact on future health care costs. This age group is 
currently the fastest growing age cohort in the United 
States, 2 and it is projected to grow from 2.5 million 
persons in 1980 to as high as 24 million persons by the 
year 2040. 3 The current health care needs of this group 
are impressive. While only 1% of those aged 65 to 74 
years reside in nursing homes, as many as 25% of women 
and 15% of men aged 85 years and older are currently 
nursing home residents. 4 Therefore, if the level of mor- 
bidity remains the same in this group (and there is no 
compelling evidence to indicate that it will change in the 
near future 5 ’ 6 ), the costs for short- as well as long-term 
health care for this age group alone may increase tenfold. 

Several measures have been proposed to reduce the 
projected growth of health care costs for older Ameri- 
cans. One approach is to reduce the per capita costs of 
care. Callahan, 7 in a companion article in this issue of 
The Journal, outlines the failures of past cost-contain- 
ment strategies. He is appropriately skeptical about 
future strategies oriented toward reducing the projected 
increasing costs of health care. Moreover, even if health 
care costs for older Americans could be reduced by 50%, 
which is a reduction that would be considered a great 
success by most, the projected 500% to 1000% increase in 
the number of those aged 85 years and older would more 

EDWARD L. SCHNEIDER, M.D., Executive Director of the 
Ethel Percy Andrus Gerontology Center and Dean of the Leonard 
Davis School of Gerontology, University of Southern California, Los 
Angeles, CA. 

Reprinted with permission from JAMA, February 10, 1989, Vol. 
261, No. 6. 

than offset these gains. 

Another response to the increasing costs of health care 
for older Americans is a proposal that age limits be set 
for the allocation of government-supported health bene- 
fits. 7 > 8 I would like to argue that age is neither a valid nor 
defensible criterion for rationing health care. In addition, 
I would like to offer an alternative course of action that I 
believe will provide a more satisfactory outcome — invest- 
ment in research targeted toward preventing those dis- 
eases that produce the greatest need for long-term care in 
our aging population. 

Without defining a specific age, Callahan proposes to 
ration life-extending high-technology health care to those 
who have completed their “natural life span.” This term 
assumes that policymakers could reach a consensus on a 
specific age when people have lived a full life. It may also 
assume that individuals complete a portion of life full of 
accomplishment and free of disability and then move to a 
period of infirmity and diminished productivity to await 
death. While an abrupt transition from health to disabil- 
ity may occur in some situations, such as fractures of the 
neck of the femur, in the vast majority of aging Ameri- 
cans this transition is gradual. Furthermore, many indi- 
viduals continue to make important contributions in 
their last years of life. 

One major problem with rationing any commodity, 
including health care, is that it often results in limited 
resources for the poor. Under the National Health Serv- 
ice in Great Britain, many aspects of health care are 
rationed. While age is not overtly mentioned as a crite- 
rion, the more expensive health care procedures, such as 
dialysis and coronary bypass surgery, are rationed by age 
and usually limited after age 55. 9 Affluent, older Britons 
have little difficulty obtaining these procedures at private 
clinics. In fact, private health care is booming in Great 

Callahan’s proposed rationing of health care for older 
Americans includes withholding Medicare reimburse- 
ment for all technology, including antibiotics, and limits 
care to providing relief from pain and suffering. 8 Cer- 

VOLUME 53, NO. 3 


tainly, physicians and relatives of affected victims need to 
consider the ethics of administering antibiotics to victims 
of Alzheimer’s disease whose quality of life is distress- 
ingly compromised. At the same time, I would vigor- 
ously oppose any proposal to eliminate Medicare enti- 
tlement for antibiotic therapy for an otherwise healthy 
85-year-old individual with acute pneumococcal pneu- 
monia. Blanket restrictions on entitlements based on age 
are irresponsible and would be difficult to administer. 
Refusing to permit hip replacements would not only lead 
to disability and dependency but would lead to increased 
costs for long-term care. Furthermore, most of the costs 
for the major diseases and disorders that disable older 
Americans — Alzheimer’s disease, osteoarthritis, and Par- 
kinson’s disease — are not currently covered by Medi- 
care, which is oriented toward short-term medical care. 

My biggest concern about health care rationing is the 
use of age as a criterion for withholding care. This is a 
step backward that removes families, affected individu- 
als, and their physicians from the decision-making pro- 
cess. Any decision to withhold care should be made 
based on other criteria such as the prognosis of the 
patient and the desires of the patient and family mem- 
bers. When age is employed as a criterion for decision 
making, it infers that older individuals make up a homo- 
geneous group. Every health practitioner is aware of the 
heterogeneity in the processes of aging. Studies of meta- 
bolic processes reveal an enormous heterogeneity of 
response to aging, with some individuals having signifi- 
cant declines in functions with aging while others have 
minimal impairment. 10 

The principal rationale employed for the rationing of 
health care based on age is to preserve resources for 
future generations. This issue of intergenerational equity 
has been raised by others to justify the need to limit 
resources for our older population to preserve them for 
younger age groups. 1 1 However, there are several weak- 
nesses in this reasoning. First, it assumes that our re- 
sources for medical care are fixed at some level. I find it 
hard to justify continuing subsidies for tobacco and 
sugar while cutting health benefits for older Americans. 
Second, there is no guarantee that the money saved 
would be reallocated to children and young adults. 
Finally, we are not taking away resources from one 
distinct group and giving them to another. Aging is a 
continuum and if death does not intercede prematurely, 
the youth of today will be the recipients of medical care 
resources in their later years. 

Future health care costs for the elderly are dependent 
on the number of individuals achieving these later years 
of life, the age-related costs of health care, and the health 
status of individuals at different ages. The numbers of 
persons reaching older ages will increase as life expect- 
ancy increases and as the “baby boomers” approach the 
last years of life. Even if the average cost of care were to 
be decreased, it is unlikely that it would diminish enough 
to offset the enormous numbers of persons who will 

reach the oldest age groups. 

I would like to offer a more optimistic and, I believe, 
rational approach to curb our burgeoning health care 
costs for older Americans, one that offers ample oppor- 
tunity to improve the health of older Americans. This is 
to increase biomedical research into the disorders that 
afflict older persons. The list of diseases and disorders 
that require increased attention includes Alzheimer’s dis- 
ease, Parkinson’s disease, osteoarthritis, and osteoporo- 
sis. The incidence of each of these disorders increases 
exponentially with aging. 12 Each produces years of dis- 
ability that require long-term health care. For example, a 
recent survey of the prevalence of Alzheimer’s disease 
among older Americans dwelling in the community 
revealed a prevalence of 4% for those aged 65 to 74 years 
and 48% for those aged 85 years and older. 13 Surveys of 
nursing homes indicate that approximately half of cur- 
rent nursing home residents have dementia, with Alz- 
heimer’s disease as the most prevalent cause. 4 In 1983, 
the cost for care of the 2 to 3 million patients with 
Alzheimer’s disease was estimated to be $38 billion. 14 As 
millions of Americans surpass age 85, the number of 
victims of Alzheimer’s disease will increase dramatically, 
resulting in enormous costs to our nation. 

Despite the very large current and projected costs for 
these diseases, significant federal research support has 
only occurred in the last few years. In contrast to the 
substantial cost of services for victims of Alzheimer’s 
disease, research funding amounted to 0.1% to 0.2% of 
the cost of services. 15 

Recognizing the enormous potential social and eco- 
nomic consequences of the acquired immunodeficiency 
syndrome, Congress has significantly increased its ap- 
propriations for research on this condition. The increased 
research support has resulted in an unsurpassed accelera- 
tion of scientific research devoted to acquired immu- 
nodeficiency syndrome during the last few years. The 
diseases and disorders associated with aging need a com- 
parable response. Successful prevention and/or cure of 
these conditions would result in significant reductions in 
projected health care costs for older Americans. 

It can be argued that the success of biomedical research 
has resulted in the increased life expectancy that is 
threatening our health care system and that further 
research might produce additional and new burdens. 
During the first half of this century, most applied bio- 
medical research was focused on acute diseases. As a 
result, the three leading causes of death at the turn of this 
century, all infectious diseases, no longer produce signif- 
icant mortality in the United States. Today, the three top 
causes of death are chronic conditions: heart disease, 
cancer, and stroke. We are now witnessing a substantial 
decline in mortality from myocardial infarction and 
stroke. As a result, more individuals are reaching the 
eighth and ninth decades of life, where diseases such as 
Alzheimer’s disease, Parkinson’s disease, and osteoarthri- 




tis take their toll. In contrast to acute diseases, these 
disorders require abundant long-term health care serv- 
ices. It is unlikely that the conquest of diseases such as 
Alzheimer’s disease could result in the emergence of 
more costly conditions. Instead, it may be possible that 
the conquest of these diseases and disorders of aging 
could lead to the compression of the needs for long-term 
care into a few short months or years. Then, the human 
life span might approach Oliver Wendall Holmes’ “one- 
hoss shay,” a shay built so well that after long use, “it 
went to pieces all at once.” 16 

To put into perspective the need for concentrating on 
preventive and therapeutic approaches, let’s examine our 
approach to other diseases that have required significant 
costs for long-term care. If 40 years ago, we had decided 
to ration care for tuberculosis, instead of providing sup- 
port for the development of new therapies, the preva- 
lence and cost of this disorder would be several magni- 
tudes greater than current costs. If we had decided to 
limit life-extending technology for polio victims instead 
of supporting the development of vaccines, we might be 
facing enormous costs for long-term care of polio vic- 
tims. Therefore, it is imperative that before we ration 
health care, we provide the necessary resources to develop 
effective preventive and therapeutic approaches to those 
diseases and disorders that disable our older population. 
We run the risk of committing an unnecessary and 
probably fatal political and ethical error unless we make 
this relatively inexpensive research effort. If we invest in 
research on the diseases of aging, we may be able to 
provide healthier, more productive, and fruitful years for 
ourselves and for future generations. 

This research was supported in part by the John D. and Catherine T. 
MacArthur Foundation Program on Successful Aging. 

I would like to thank T. Franklin Williams, MD, Jacob Brody, MD, 
Christine Cassel, MD, Carrol L. Estes, PhD, Hilary Siebens, MD, and 
Leah Buturain Schneider, MS, for their suggestions and Lorren Luchi 
and Lori Rosenquist, MS, for their assistance. 

1. Annual Medicare Program Statistics: Medicare Enrollment Re- 
imbursement and Utilization, 1983, Healthcare Financing Admin- 
istration publication 03224. Baltimore, Bureau of Data Manage- 
ment and Strategy, 1987. 

2. Rosenswaike IA: Demographic portrait of the oldest old. Milbank 
Q 1985;63:187-205. 

3. Guralnik JM, Schneider EL, Yanagishita M: Projecting the older 
population of the United States; Lessons from the past and pros- 
pects for the future. Milbank Q 1988;66:283-308. 

4. Hing E: Use of Nursing Homes by Elderly- Preliminary Data From 
the 1985 National Nursing Home Survey, Advance Data From 
Vital and Health Statistics No. 135, publication 87-1250. Hyatts- 
ville, Md, Health Care Financing Administration, 1987. 

5. Manton KG: Changing concepts of morbidity and mortality in the 
elderly population. Milbank Q 1982;60:183-244. 

6. Guralnik JM, Schneider EL: The compression of morbidity: A 
dream which may come true someday. Gerontologica Perspecta 

7. Callahan D: Old age and new policy. JAMA 1989;261:905-6. 

8. Callahan D: Setting Limits: Medical Goals in an Aging Society. 
New York, Simon & Schuster Inc Publishers, 1987. 

9. Aaron HJ, Schwartz WE: The Painful Prescription: Rationing 
Hospital Care. Washington, DC, The Brookings Institution, 1984. 

10. Finch CE, Schneider EL: Handbook of the Biology of Aging. New 
York, Van Nostrand Reinhold Co, 1985. 

1 1 . Preston S: Children and the elderly: Divergent paths for America’s 
dependents. Demography 1984;21:435-57. 

12. Brody JA, Schneider EL: Diseases and disorders of aging: A 
hypothesis. J Chronic Dis 1986;39:871-6. 

13. Moss M, Alpert M: Alzheimer’s disease and other dementing 
disorders, in Alpert MS, Moss M (eds): Geriatric Neuropsychol- 
ogy. New York, Guilford Press, 1988, pp 145-78. 

14. Hu T, Cartwright WS: Evaluation of the costs of caring for the 
senile demented elderly: A pilot study. Gerontologist 1986;26: 

15. Weiler PG: The public health impact of Alzheimer’s disease. Am J 
Public Health 1987;77:1157-8. 

16. Holmes OW: The Complete Poetical Works of Oliver Wendell 
Holmes. Boston, Houghton Mifflin Co, 1908. 

VOLUME 53, NO. 3 


Consider a few features of 

The Western Journal of Medicine: 

• Epitomes of Progress — Each month this set 
tion highlights the major advances in a differer 
specialty with 15 or 20 brief epitomes by 
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research findings, emphasizing clinical value. 

• Socioeconomics — WJM is often the first to 
predict, examine and evaluate socioeconomic 
changes, trends. 

• Yearly Special Issue — Each December’s 
issue is devoted to a topic vital to physicians: 
clinical nutrition ( 1979 ) , cost of care ( 1980 ) , 
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( 1982), cross-cultural medicine ( 1983), per- 
sonal health maintenance ( 1984 ) , high-tech 
medicine ( 1985 ) , medical informatics ( 1986 ) 

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Procedures for Screening Nursing Home Applicants 


T HIS memorandum summarizes briefly recent fed- 
eral statutory requirements governing the admis- 
sion of patients to nursing homes. The State of Connec- 
ticut Department of Income Maintenance is accountable 
for compliance with this new Act and is seeking the 
assistance and cooperation of the medical community, as 
well as nursing homes and hospitals, in assuring efficient 
and appropriate implementation. Procedures for com- 
pleting and seeking reimbursement for physician services 
to nursing home applicants are described below. 

The federal “Nursing Home Reform” provisions of 
the Omnibus Budget Reconciliation Act of 1987 man- 
date that no person (regardless of payment source) be 
admitted to a nursing home after 1 January 1989, unless 
that person has been screened to determine whether he or 
she requires active treatment for mental illness or mental 
retardation. For the vast majority of people, this will 
simply require the completion of an identification form 
which lists key criteria indicating a possible condition of 
mental illness or mental retardation. This identification 
form will be completed by hospitals for their patients, 
j and by nursing homes for applicants from the commun- 
ity. If the nursing home does not have sufficient informa- 
tion about the prospective resident to complete the iden- 
tification form, the identification form will be sent to the 
applicant’s physician along with a self-addressed stamped 
envelope to return the form to the Department. 

We ask that you complete the identification form 
j within two days of receipt. 

If the identification form indicates that the person 
does not have a positive indication as defined by the 
' criteria, or if the person is exempt as outlined on the 
identification screen, no further reviews are necessary, 
and all current state preadmission screening and admis- 
sion procedures apply. If, however, the identification 
form indicates the need for further evaluation, a more 

LINDA J. SCHOFIELD, Director, Medical Care Administration, 
| Department of Income Maintenance. State of Connecticut, Hartford, 
CT 06106. 

extensive assessment is required to determine definitely 
whether the person needs active treatment for mental 
illness or mental retardation. 

The first step in this assessment is the completion of a 
Medical Supplement Form by a physician or another 
health professional familiar with the patient’s medical 
condition and history. For community-residing patients, 
the nursing home will send the physician (with the identi- 
fication form — unless it has already been completed) a 
Medical Supplement form. Please complete and sign the 
medical supplement form only if the identification form 
indicates that the patient requires further evaluation. 

If the individual has not had a physical examination 
within one year, then a physical must be performed prior 
to completing the Medical Supplement Form. We ask 
that you return the appropriate completed forms to the 
Department within ten working days of receipt in order 
to assure timely service to the patient. 

Additional screening forms will usually be completed 
by hospital staff or the Department Preadmission Screen- 
ing field office staff. However, physicians may occasion- 
ally be asked to complete these forms for their hospital- 
ized patients. One of these forms is the Uniform Health 
Screen, which is currently being used in the Preadmis- 
sion Screening and Community-Based Services Program 
to collect data on the person’s functional and psychoso- 
cial status. The other forms have been designated by the 
Department of Mental Health to collect data and service 
information related to a possible condition of mental 
illness. These are the Psychotic Inpatient Profile Form 
(“PIP”) and the profile of services. 

The federal law specifically requires that the preadmis- 
sion screening process must be completed before a patient 
can be admitted to the nursing home. Failure to comply 
could result in the loss of federal Medicaid funding and 
decertification of the long-term care facility. The law 
provides for no exceptions to this process, although the 
state has authorized emergency admissions for persons 
whose health and safety are endangered. 

VOLUME 53, NO. 3 


In order to assure that this screening process does not 
delay hospital discharges or nursing home admissions, the 
state has instructed providers to identify potential nursing 
home admissions and initiate the screening process as early 
as possible. Hospitals will be identifying potential nursing 
home discharges within three days of admission and com- 
pleting all of the appropriate forms. Nursing homes are 
required to start the screening process on applicants resid- 
ing in the community when it is projected that a bed will be 
available in approximately 60 days. 

The Department will pay physicians $11.05 for com- 
pletion of a Medical Supplement form, $30.42 for per- 
forming a physical if one is necessary, and $55.00 for 
completion of (on a hospitalized patient) a required 
evaluation of mental illness (psychotic inpatient profile 
form). These payments are available for both Medicaid 
and non-Medicaid nursing home applicants. Federal 
guidelines prohibit payment for completion of the iden- 

tification form. Details on the payment procedures are 
still being finalized; this information will be conveyed to 
you as soon as possible. But, in the meanwhile, the 
Department will keep track of all services provided and 
will assist you with appropriate billing, if required, in the 
future. Please note, however, that the Department will 
not pay for procedures that were not required to comply 
with the preadmission screening law. 

If you believe that the response to questions on the 
identification form “falsely” indicates the need for further 
evaluation, please call Ginnie Getchell at 566-6646 to 
discuss the case. You should also contact Ginnie if you 
have other questions about the screening process. 

The Department is actively working with providers to 
make this mandatory process as efficient as possible. We 
ask for your patience and cooperation, and welcome any 
suggestions as we work to improve this system. Thank 
you for working with us to serve our patients. 

Mortality Trends — United States, 1986-1988 

The leading causes of death in the United States are monitored by mortality data from the National Vital Statistics 
System (see page 118). In 1986, 1987, and the 12-month period October 1, 1987, to September 30, 1988, death rates 
decreased for some of the leading causes of death, including two of the three leading causes: heart disease and stroke (Table 
1). However, the rate for the second leading cause, cancer. 

TABLE 1. Annual death rates per 100,000 population for the 10 leading causes of death — United States, 1986, 1987, and 
October 1, 1987— September 30, 1988* 



Cause of death (ICD-9) 

Final § 




1987 9/30/88 






Diseases of heart (390-398,402,404-429) 





Malignant neoplasms, including neoplasms of lymphatic 
and hematopoietic tissues (140-208) 





Cerebrovascular diseases (430-438) 





Accidents and adverse effects (E800-E949) 




Motor vehicle accidents (E810-E825) 




All other accidents and adverse effects 
(E800-E807, E826-E949) 





Chronic obstructive pulmonary diseases and allied 
conditions (490-496) 





Pneumonia and influenza (480-487) 





Diabetes mellitus (250) 





Suicide (E950-E959) 





Chronic liver disease and cirrhosis (571) 





Atherosclerosis (440) 




* References 1-3. 
t Based on a 10% sample. 
§ Based on all deaths. 


1 . National Center for Health Statistics. Advance report of final mortality statistics, 1986. Hyattsville, Maryland: US Department of Health and 
Human Services, Public Health Service, 1988; DHHS publication no. (PHS)88-1 120. (Monthly vital statistics report; vol 37, no. 6, suppl). 

2. National Center for Health Statistics. Annual summary of births, marriages, divorces, and deaths: United States, 1987. Hyattsville, Maryland: 
US Department of Health and Human Services, Public Health Service, 1988; DHHS publication no. (PHS)88-1 120. (Monthly vital statistics 
report; vol 36, no. 13). 

3. National Center for Health Statistics. Births, marriages, divorces, and deaths for October 1988. Hyattsville, Maryland: US Department of 
Health and Human Services, Public Health Service, 1989; DHHS publication no. (PHS)89-1 120. (Monthly vital statistics report; vol 37, no. 10). 

4. CDC. Chronic disease reports in the Morbidity and Mortality Weekly Report (MMWR). MMWR 1989;38(suppl S-l). 

— Morbidity and Mortality Weekly Report, March 3, 1989. 



Hospital Spending in the United States 
and Canada: A Comparison 


Prologue: The rate at which Canada’s citizens are hospi- 
talized is high (1,242 days per 1,000 residents) and the 
lengths-of-stay for all levels of care in private voluntary 
hospitals long (11.5 days). Canada’s hospitals negotiate 
their budgets every year with, for all practical purposes, 
the lone payer of care — the provincial health insurance 
plan where they operate. In this paper, Joseph New- 
house, Geoffrey Anderson, and Leslie Roos explore the 
question: What accounts for the substantial differences 
in hospital spending between such institutions in Canada 
and the United States? Comparisons both between and 
within countries are complicated by the difficulty of 
defining similar hospitals and similar patient popula- 
tions. Nevertheless, the question they address is compel- 
ling and warrants examination. Newhouse, an econo- 
mist, is the John D. and Catherine T. Mac Arthur Pro- 
fessor of health policy and management at Harvard 
University. He holds a joint appointment at the Harvard 
Schools of Government, Medicine, and Public Health. 
Newhouse is also codirector of the Harvard- RAN D- 
UCLA consortium, which provides policy analysis on 
selected health issues to the Health Care Financing 
Administration. Before joining the Harvard faculty this 
summer to build a strong doctoral program in health 
policy, Newhouse directed The RAND Corporation’s 
Economics Department. He was the principal investiga- 
tor of RAND’s fifteen-year, $82 million, federally funded 
health insurance study, the largest randomized trial of 
health care financing ever undertaken. Anderson, a phy- 
sician who also holds a doctorate in health policy from 
the RAND graduate program, is on the faculty of the 
University of British Columbia. Roos, who received his 
doctorate in political science from the Massachusetts 
Institute of Technology, is a member of the faculty of 
management at the University of Manitoba. Roos has 
built a distinguished career in health services research, in 
part by mining a rich claims database maintained by 
Manitoba’s provincial health insurance plan. 

The following five articles are reprinted with permission from the 
Winter 1988 Issue of Health Affairs Project HOPE. 

N UMEROUS health policy analysts on both sides of 
the border have discussed the Canadian method of 
financing medical care as a possible model for the United 
States. 1 Canada not only has achieved universal cover- 
age but spends substantially less per capita on health 
than the United States. Those favoring the Canadian 
model have tended to assume that the savings in cost 
come with minimal or no effect on the quality of care or 
health outcomes. On the contrary, because of universal 
coverage, health outcomes averaged over the Canadian 
population as a whole may even exceed those in the 
United States. However, the U.S. debate over whether 
the Canadian system is superior has paid less attention to 
health outcomes than to differences in cost and coverage 
levels. In Canada, by contrast, there is no serious advo- 
cate of the U.S. system. 

In this article, we do not examine differences between 
the two countries in health outcomes, but we do examine 
the differences in the use of acute care hospitals — the 
largest single component of health care expenditures in 
both countries. We compare the countries in terms of 
three measures of hospital utilization: (1) admissions, 
(2) length-of-stay, and (3) case-mix, measured using the 
weights attached to the diagnosis-related groups (DRGs) 
of the U.S. Medicare program. We limit the analysis to 
the care provided to individuals age sixty-five and older 
because they receive universal public insurance in both 
countries. 2 Thus we can attribute differences in use to 
factors other than differences in insurance coverage and 
can compute rates of use for defined populations. While 
our analysis does not compare the ultimate effects of 
differences in health care expenditures between the two 
countries, it does provide a first step toward a better 
understanding of the factors that drive those differences. 
Hospital Use In The United States And Canada 
We compare utilization in two Canadian provinces 
with both the United States as a whole and selected states 
geographically close to the two provinces. We chose the 
two provinces because of data availability. However, 
they contain 40 percent of the Canadian population; 
also, results for the two provinces are similar, suggesting 

VOLUME 53, NO. 3 


that our conclusions may hold for a comparison of all of 
Canada with the United States. 

Data sources and numbers. For the United States, our 
data come from a 20 percent sample of all Medicare 
hospital claims in calendar year 1981 and fiscal years 
1984 and 1985. From this file we deleted claims from the 
four states that at that time had waivers from the pro- 
spective payment system (PPS) — Maryland, Massachu- 
setts, New Jersey, and New York. Thus, references to the 
entire United States mean only forty-six states. We also 
deleted claims from Puerto Rico and the Virgin Islands, 
although including them would have negligible effects 
because they are so small. We also deleted claims for 
those under age sixty-five. 

For Canada, the data come from a 100 percent sample 
of claims from Ontario and Manitoba. Although we 
compare both provinces with the entire United States, 
we also compare Ontario with Michigan and Ohio, and 
Manitoba with North Dakota and Montana. The sam- 
ples from each of the two-state areas are about half as 
large as the comparable provinces. 

Type of provider and case-mix. The goal of our analy- 
sis was to compare the use of acute care hospital services 
in the two countries. However, differences in the defini- 
tions of institutions and units exist. To make our com- 
parisons as similar as possible, we excluded cases in 
rehabilitation and long-term care hospitals and units. 
We used the following methods to define use of acute 
care beds. 

In Ontario, each discharge abstract contains a variable 
that identifies the institution from which the individual 
was discharged. Each institution is assigned a unique 
identifier. Long-term care and rehabilitation units within 
acute care hospitals are assigned identifiers that are dis- 
tinct from the number assigned to the acute care section 
of the hospital. A transfer from an acute care section to a 
rehabilitation or long-term care section of the same insti- 
tution produces a discharge abstract. A discharge was 
included in the analysis only if it was from an identified 
acute care institution. Discharges from acute care psy- 
chiatric units were included. 

In Manitoba, each discharge abstract contains a : ser- 
vice code indicating the type of care received by the 
patient during the admission. Patients receiving personal 
care, physical medicine and rehabilitation, geriatrics, 
and extended treatment were excluded from the analysis. 
Patients receiving psychiatric or psychogeriatric care 
were included. 

In the United States, certain hospitals — rehabilitation, 
chronic or long-term, psychiatric, and children’s — were 
exempt from PPS, which began in October 1983. Unfor- 
tunately, we cannot identify these exempt hospitals in 
1981. We have therefore estimated 1981 admission and 
case-mix figures using the relationship between acute 
care hospitals (and psychiatric hospitals) and all hospi- 
tals in 1984 and 1985. Specifically, to estimate a figure for 

admissions and the case-mix index for 1981, we used the 
admission (case-mix) figure for all hospitals for 1 98 1 and 
multiplied it by the ratio of admissions (case-mix) in all 
hospitals other than long-term and rehabilitative to 
admissions (case-mix) in all hospitals. This ratio was 
available for both 1984 and 1985; we averaged the two 

Only around 5 percent of all admissions occurred in 
rehabilitative and long-term care hospitals and units in 
both 1984 and 1985, and, if anything, the value was 
probably lower in 1981 because of fewer such units. Our 
method for estimating a 1981 rate therefore effectively 
decreased the admission rate to all hospitals (including 
rehabilitative and long-term) in 198 1 by about 5 percent. 
The resulting 1981 admission rate for the United States 
may be slightly too low, but any error is almost certainly 
not serious enough to affect the comparisons with 

The value for the case-mix index is about 1 percent 
higher in both 1984 and 1985 if cases in rehabilitation 
and long-term hospitals and units are excluded. Hence, 
our methods led us to increase the case-mix index for all 
hospitals in 1981 by about 1 percent. That adjustment 
also does not affect any of our comparisons. 

Length-of-stay. Unlike admissions and the case-mix 
index, the 1981 length-of-stay values are sensitive to the 
adjustment process, because of the long lengths-of-stay 
in rehabilitation and long-term care hospitals and units 
(mean values in the United States of fifty days in 1984 
and thirty-five days in 1985). To reduce the sensitivity of 
our length-of-stay comparisons to errors in classification 
of cases, we began by computing not only the usual mean 
but also a trimmed mean by setting all stays of over sixty 
days equal to sixty days. This reduces the influence of 
very long-stay cases. However, when we then adjusted 
the 1981 U.S. values in the same way that we adjusted 
admissions and case-mix, we obtained the anomalous 
result that the adjusted trimmed length-of-stay exceeded 
the adjusted untrimmed length-of-stay. Hence, we have 
followed the simple step of reporting the length-of-stay 
values for all U.S. hospitals for 1981 (both untrimmed 
and trimmed). Although this will overestimate length-of- 
stay in hospitals other than rehabilitation and long-term, 
the values are still well below the Canadian values, so 
that our qualitative conclusions are unaffected. In the 
U.S. data, we have excluded discharges from skilled 
nursing facilities. 

Population data. U.S. enrollee data come from the 
Health Care Financing Administration (HCFA). These 
data are for 1984 and come from aggregating enrollees 
by zip code. To project the number of enrollees for 1981 
and 1985, the total number of Part A enrollees over age 
sixty-five in 1981, 1984, and 1985 in the entire country 
was used. 3 The number of enrollees in each of the two 
subregions analyzed in 1981 and 1985 was assumed to 
change proportionally the same as the national number 
(0.9439 for 1981 and 1.0211 for 1985, both relative to 



1984). In Canada, federal support for the provincially 
administered health care systems is contingent upon uni- 
versal coverage of the population. Therefore, census data 
were used to identify the eligible populations in Ontario 
and Manitoba. 

We have not age- and sex-adjusted our figures because 
the age-sex distributions are virtually identical. Using 
five-year age groups for each sex (through age eighty- 
five), the percentage of the population in each group in 
North Dakota and Montana is always within one per- 
centage point of the group in Manitoba; similarly, the 
percentage for Michigan and Ohio is almost always 
within one percentage point of the group in Ontario (one 
case differed by 1.3 points). We cannot compare costs or 
charges at the case level directly because Canada does 
not associate costs or charges with a particular case in its 
global budgeting method. 

Results Of The Comparison 

As is commonly known, real personal health expendi- 
ture per person is substantially higher in the United 
States than in Canada; we estimate that the United 
States spent about 50 percent more per person through- 
out the first part of the 1980s (Exhibit 1). Similar percent- 
age differentials also applied to hospital services. Hospi- 
tal expenditure per capita in Manitoba is identical to that 
in all of Canada. 

Exhibit 1 

Health Expenditure Per Capita In The U.S. And Canada, 1981-1985, 1985 U.S. Dollars 3 


United States 



Personal health 
per capita 

per capita 

Personal health 
per capita 

per capita 

per capita 




$ 800 















Sources: Data for United States 1981, 1984, K. R. Levit et al., "National Health Expenditures, 1984.” Health Care 
Financing Review (Fall 1985); for 1985, D. Waldo et al., “National Health Expenditures, 1985," Health Care 
Financing Review (Fall 1986). Data for Canada, National Health Expenditures in Canada, 1975-1985 ; National Health 
and Welfare, 1987; Quarterly Economic Review, Annual Reference Tables (Department of Finance, Canada, June 
1987); Manitoba Health Services Commission, Annual Reports. Converted to U.S. dollars at exchange rates of 
1.199 for 1981, 1.295 for 1984, and 1.366 for 1985. 

■Uses United States gross national product (GNP) consumption deflator. 

To examine in more detail what might account for 
these differences in the level of hospital expenditure, we 
examined admission rates and lengths-of-stay between 
1981 and 1985 (Exhibits 2 and 3). Admission rates were 
comparable between Michigan/ Ohio and Ontario in 
1981 and 1984, and were lower in Michigan in 1985. 
Although admission rates in Montana/ North Dakota 
fell 15 percent from 1984 to 1985, they remained about 10 
percent above those in Manitoba and well above those 
for the United States. On the whole, by 1985, admission 
rates in the two countries seem approximately the same. 
In contrast, length-of-stay differs markedly between the 

Exhibit 2 

Hospital Admission Rates For People Over Age Sixty-Five, Selected States And Provinces 






North Dakota/ 

All United 



.33 b 


.41 b 

•34 b 













* Excludes waiver states of Maryland, Massachusetts, New Jersey, and New York. 
b Esti mated; see text. 

two countries. Length-of-stay in Manitoba was approx- 
imately double the length-of-stay in Montana/ North 
Dakota, while length-of-stay in Ontario was notably 
longer than in Michigan/ Ohio, especially by 1985. North 
Dakota/ Montana had somewhat shorter stays than the 
U.S. average, and Michigan/ Ohio had somewhat longer 

Exhibit 3 

Length-Of-Stay For People Over Age Sixty-Five, Selected States And Provinces, In Days 






North Dakota/ 

All United 



11. U h 


8.35 b 

9.90 b 













* Excludes waiver states of Maryland, Massachusetts, New Jersey, and New York. 

b Value is overestimated because it includes stays at rehabilitation and long-term care hospitals and units; see text. 

To determine how length-of-stay might be affected by 
very long-stay patients, we recomputed the mean length- 
of-stay by trimming stays at sixty days (that is, patients 
with stays longer than sixty days were set equal to sixty 
days). The results are shown in Exhibit 4. Stays in 
Manitoba are particularly affected, falling by three to 

Exhibit 4 

Length-Of-Stay For People Over Age Sixty-Five, Selected States And Provinces, Stays 
Trimmed At Sixty Days 






North Dakota/ 

All United 
States ' 



10.98 b 


8.23 b 

9.75 b 













a Excludes uaiver states of Maryland, Massachusetts, New Jersey, and New York. 
b Value for all hospitals; see text. 

four days. Values for the United States are not much 
changed. Nonetheless, even after reducing the effect on 
the mean of these very long-stay patients, there remain 
substantial differences between the countries in mean 

Results for the case-mix index are somewhat difficult 
to interpret because of the rapid increase in the U.S. 
index, much of which has been attributed to better cod- 
ing procedures (Exhibit 5). 4 By contrast, the values for 
Canada have increased at a rate of half a percent to a 
percent a year, which is similar to the pre-PPS trend of a 
half percent a year that Grace Carter and Paul Ginsburg 
estimated for the United States. 5 

Exhibit 5 

Case-Mix Index For People Over Age Sixty-Five, Selected States And Provinces 






North Dakota/ 

All United 



1.08 b 


0.96 b 

1.01 b 













* Excludes waiver states of Maryland, Massachusetts, New Jersey, and New York. 
b Estimated; see text. 

What Accounts For The Difference? 

In the early 1980s, the United States spent nearly 50 
percent more per person on hospital services than Can- 
ada; the important question is what, if anything, the 
United States bought for that additional expenditure. To 
shed light on that question, we have decomposed hospi- 
tal spending in two provinces and compared the anat- 
omy of that spending with two comparable areas in the 

VOLUME 53, NO. 3 


United States and the United States as a whole. 

Overall, our findings, which apply only to the elderly, 
somewhat deepen the puzzle of what the United States 
might be buying. By 1985, admission rates were roughly 
comparable in the two countries, being somewhat higher 
in North Dakota and Montana than in Manitoba, but 
somewhat lower in Michigan and Ohio than in Ontario. 
The U.S. admission rate was marginally below that of 
the two provinces. Hence, the differences in spending 
between the two countries cannot be attributed to a 
higher rate of hospital admissions in the United States. 

In each of the three years we examined, lengths-of-stay 
were markedly longer in Canada. The considerable fall 
in length-of-stay in the United States was not matched in 
Canada. By 1985, lengths-of-stay in Ontario were more 
than two-thirds again as long as in Michigan and Ohio, 
and in Manitoba were more than double the lengths-of- 
stay in North Dakota and Montana. Because admission 
rates were roughly similar (in 1985), the number of 
patient days per person over age sixty-five in the United 
States are only 50 to 60 percent of the corresponding 
number in Canada. It follows from the values in Exhibit 
1 that spending per patient day is perhaps three times as 
great in the United States as in Canada. 

Case-mix. To understand why the United States might 
be spending half again as much per case and three times 
as much per day, we examined the case-mix index for the 
two countries. Comparison between the two countries is 
complicated by the rapid rate of increase in the U.S. 
index that can be attributed to PPS. Coding now affects 
the hospital’s reimbursement; this has resulted in both a 
substantial increase in the accuracy of the coding and an 
incentive to code cases in higher-weighted DRGs. Neither 
of these effects was present in Canada. 

If we judge the comparability of case-mix using data 
from 1981, a time when coding incentives in the two 
countries were more nearly similar, the case-mix index is 
higher in Canada; this is especially true of the compari- 
son between Manitoba and North Dakota/ Montana. In 
1984 the two countries were roughly comparable, al- 
though by 1985 the United States had a somewhat higher 
case-mix index. If one could adjust for upcoding, how- 
ever, it is likely that the 1985 U.S. value would be equal to 
or below the Canadian. 6 The similarity of the annual 
change in case-mix in Canada with the annual U.S. 
change prior to PPS strongly suggests that most of the 
change in the United States was not true change. Even if 
the 1985 difference between the United States and Can- 
ada is true (which we think is unlikely), case-mix, as 
measured by DRGs, can at best account for only a small 
portion of spending differences. 

Thus, the difference in hospital spending between the 
two countries, which may account for around 40 percent 
of the difference in total expenditure between the two 
countries, must be accounted for primarily by differences 
in the cost of a “case-mix index unit” per beneficiary. 

With admissions and the case-mix index in the two 
countries at approximately the same level, the cost of a 
case-mix unit in the United States was approximately 50 
percent higher than in Canada. What might account for 
such a difference? The Canadian method of global 
budgeting, of course, makes it easier to control costs, and 
some discussions appear to assume that the additional 
American costs are pure inefficiency. However, other 
factors ought to be considered. 

Severity of illness. Differences in severity or complex- 
ity within DRGs could be such that American patients 
are sicker. There is no reason, however, to think that this 
is the case; indeed, the similar admission rates and longer 
lengths-of-stay in Canada, if anything, point in the other 
direction. Lack of insurance coverage, which could lead 
to increased severity of illness in some under age sixty- 
five admitted to a U.S. hospital, should not play an 
important role in the Medicare population. 

Volume of services. American patients could have 
more done to or for them when in the hospital. Not only 
could there be more tests and other ancillary procedures, 
but staffing ratios could be higher. Indeed, staffing ratios 
per patient day in the United States appear to be almost 
double those in Ontario. There were 3.47 employees per 
adjusted census in nonfederal short-term general and 
other special hospitals in the United States in 1981, and 
1.87 per inpatient day in 1980-1981 in Ontario. 7 How- 
ever, staffing ratios per stay or per person in the popula- 
tion are not very discrepant between the two countries. 

Higher-paid staff. Employees of American hospitals 
could be paid more than similar employees at Canadian 
hospitals. We do not have data on wages. Hospital 
inputs other than personnel (for example, beds) tend to 
be traded in international markets, so their costs should 
not much differ between the two countries. 

Administrative costs. Certain overhead or administra- 
tive costs may differ. For example, malpractice premi- 
ums no doubt are higher in the United States than in 
Canada. (Note, however, that one justification of the 
malpractice system is deterrence of negligent actions, 
which, if it were effective, ought to lower U.S. hospital 
costs relative to Canadian.) Administrative costs to cope 
with multiple sources of financing and various utilization 
review mechanisms also may be higher in the United 
States. However, it is unlikely that such differences could 
begin to account for the magnitude of the overall differ- 
ence in spending, because total administrative and ac- 
counting costs are estimated to account for only 18 
percent of U.S. expenditure on personal health care 
versus 8 percent in Canada. 8 

A Closer Look At Length-Of-Stay Differences 

Our work points up the methodological difficulties of 
making comparisons across countries. Although our 
major conclusions do not appear sensitive to definitional 
differences, the difficulties in developing comparable 
definitions of hospitals may be a problem for more 



detailed analysis of the two countries. Indeed, even 
within each country there are difficulties with hospital 
definition. For example, the figures often cited to show 
the decline in length-of-stay caused by PPS do not com- 
pare patients in the same hospitals over time. * 1 2 3 4 5 6 7 8 9 As a result, 
the well-known fall in length-of-stay resulting from PPS 
is overstated. If one includes patients in exempt hospitals 
in 1981 and 1984, average length-of-stay actually rose 
among those age sixty-five and over, from 9.9 days to 
10.7 days in 1984; in 1985, however, length-of-stay fell to 
9.5 days. 10 

Because of the importance of hospital definition in the 
number of long-stay patients and the importance of such 
patients in the overall length-of-stay figures, we com- 
pared the percentage of patients in the two countries with 
stays of over sixty days. Two conclusions emerged (Ex- 
hibit 6). First, U.S. data for all hospitals show a substan- 
tial increase in long-stay patients between 1981 and 1985. 
At the same time, long-stay patients in PPS-covered 
hospitals have decreased. (Of course, PPS gives a con- 
siderable reward for caring for long-stay patients in 
exempt hospitals or units.) Hence, average length-of- 
stay figures will be sensitive to the definition of hospital 
used and to the nature of patients in those hospitals. 

Exhibit 6 

Percentage Of Patients Over Age Sixty-Five Staying Over Sixty Days 




United States 

All hospitals 0.5 

All excluding rehabilitation and long-term 





Ontario* 2.7 

Manitoba 15 5.0 





’All patients excluding rehabilitation and long-term. 

b Excludes stays in personal care units, geriatrics, and extended treatment hospitals. 

Second, comparing the United States with Ontario 
and Manitoba shows that the proportion of patients with 
very long stays is considerably greater in Canada, espe- 
cially in Manitoba; this proportion has been increasing 
in Ontario as well as in the United States (though not in 
Manitoba). The proportion of elderly with very long 
stays also has been increasing in British Columbia. 11 * * The 
reasons for this increase remain to be explored, but a 
small increase can cause a dramatic change in the aver- 
age length-of-stay. For example, the average U.S. length- 
of-stay for patients staying over sixty days in 1985 was. 
130 days. Hence, a one-percentage-point increase in such 
patients will raise average length-of-stay 1.3 days. Given 
the increases in long-stay patients, government insurers 
might well want to investigate ways to reduce length-of- 

Although this is only a first look at comparing Canada 
and the United States, patients at U.S. hospitals appear 
to use either more inputs or more highly paid inputs (or 
both) than do patients at Canadian hospitals. This dif- 
ference in intensity appears to account for the bulk of the 
difference in hospital spending between the two coun- 
tries. If so, the ultimate question is what the United 
States buys with the additional intensity, if anything. 
That question can best be addressed with data that per- 

tain to outcomes. The most readily available outcome 
data are mortality data, but they are too crude to answer 
the question. Readmissions data for complications and 
other poor outcomes following surgery are another 
available indicator of outcome. Lacking comprehensive 
measures of outcome, one reasonable next step is to 
pursue the type of analysis used here at the level of 
specific diseases and treatments. 

Newhouse acknowledges and thanks The RAND Corporation for 
supporting this work from its own funds. He thanks Daniel Byrne for 
computational assistance. This work was also supported in part by a 
Career Scientist Award No. 6607-1314-48 from Health and Welfare, 
Canada (to Roos), by the Manitoba Ministry of Health, the Ontario 
Ministry of Health (Grant 02024), the Woodward and Vancouver 
Foundations, and the British Columbia Ministry of Health. Nothing 
expressed herein should be construed as representing the views of any 
of the above sponsoring organizations. 


1. S. Andreopoulos, ed.. National Health Insurance: Can We Learn 
from Canada? (New York: John Wiley & Sons, 1975); and J.K. 
Iglehart, “Canada’s Health Care System,” The New England 
Journal of Medicine (July and September 1986): 202-208 and 

2. In the United States, the widespread nature of so-called Medigap 
policies makes cost sharing for hospital services among those over 
sixty-five unimportant. Approximately 75 percent of people over 
sixty-five were covered by Medigap policies, and another 8 percent 
were covered by Medicaid, although not all Medigap policies cover 
all cost sharing. The remaining sixth face a deductible equal to the 
average cost of one day in the hospital. United States Department 
of Commerce, Statistical Abstract, 1988 (Washington, D.C.: U.S. 
Government Printing Office, 1987). 

3. United States Department of Commerce, Statistical Abstract, 
1987 (Washington, D.C.: U.S. Government Printing Office, 1986). 

4. G. Carter and P.B. Ginsburg, The Medicare Case- Mix Index 
Increase: Medical Practice Changes, Aging, and DRG Creep, Pub. 
no. R-3292-HCFA (Santa Monica, Calif.: The RAND Corpora- 
tion, 1985). 

5. Ibid. 

6. Ibid. 

7. American Hospital Association, Hospital Statistics, 1986 (Chi- 
cago: AHA, 1986): and A. Detsky, S.R. Stacey, and C. Bombard- 
ier, “The Effectiveness of a Regulatory Strategy in Containing 
Hospital Costs — The Ontario Experience, 1967-1981,” The New 
England Journal of Medicine (21 July 1988): 151-158. 

8. These numbers are suspect because definitions may not be com- 
parable; even so, they demonstrate that it is unlikely that differ- 
ences in administrative costs could account for a majority of the 
difference. D.U. Himmelstein and S. Woolhandler, “Cost Without 
Benefit,” The New England Journal of Medicine (13 February 
1986):44 1-445. 

9. J.P. Newhouse and D.J. Byrne, “Did Medicare’s Prospective 
Payment System Cause Length-of-Stay to Fall T Journal of Health 
Economics (December 1988), forthcoming. 

10. The trimmed mean (trimmed at sixty days) fell from 9.7 days in 
1981 to 9.5 days in 1984 to 8.9 days in 1985. Standard errors on the 
untrimmed means are around 0.01 to 0.02. 

11. R.G. Evans et al., “The Long Good-bye: The Great Transforma- 

tion of the British Columbia Hospital System,” University of 

British Columbia, Discussion Paper HPRU 88:2, March 1988. 

VOLUME 53, NO. 3 


Perspectives: Canada 

Split Vision: Interpreting Cross-Border Differences In Health Spending 


F OR roughly two decades, North America has been 
the site of a vast social experiment on the effects of 
alternative ways of paying for health care. Conducted in 
real time, with entire populations and real bullets — no 
compensation if things work out badly — the “experi- 
ment” has nonetheless been quasi-controlled. Our two 
societies, Canada and the United States, are about as 
similar in language and culture as one can expect in an 
imperfect world, and have significant parallels in geog- 
raphy and historical experience. We have even had very 
similar medical care systems, at least at the beginning of 
the experiment. 

Comparing The Two Approaches 

The recognition that our divergent approaches offered 
a remarkable opportunity for better understanding of 
the effects of health policy emerged prominently at the 
Sun Valley Conference of 1974. 1 Theodore Marmor 
provided a particularly clear discussion of the “most 
similar case” approach to learning from cross-national 
experience, and has drawn heavily on the “North Ameri- 
can experiment” in subsequent analyses of U.S. health 
insurance proposals. 2 

The quantitative analysis of comparative system per- 
formance, however, has had to wait upon both the 
accumulation of sufficient years of observation to carry 
conviction and the evolution of comprehensive and 
accessible databases describing the two systems in com- 
parable terms. Only within the past five years has a 
substantial literature begun to develop, describing and 
interpreting the results to date. This paper by Joseph 
Newhouse, Geoffrey Anderson, and Leslie Roos makes 
a useful contribution to that literature, confirming results 
that had emerged from more general studies and high- 
lighting significant issues for further exploration. 

ROBERT EVANS, professor of economics at the University of 
British Columbia in Vancouver, has been researching Canadian and 
U.S. health care costs for twenty years. He is director of the Program in 
Population Health of the Canadian Institute for Advanced Research, a 
National Health Research Scientist, and a prolific writer on the subject 
of Canadian/ U.S. health systems. 

The most obvious quantitative result from the “exper- 
iment” has been the stabilization of health expenditures 
in Canada, as a share of gross national product (GNP). 
Contrary to widespread impression, and generalization 
from elementary economic models, universal “free” care 
led not to cost explosion but to cost control. This is in 
marked contrast to experience both in the United States 
and Canada prior to 197 1 . Recent work by Tony Culyer 
shows that the Canadian record of cost control after 
1971 also stands out against the background of the 
Organization for Economic Cooperation and Develop- 
ment (OECD) countries as a group, a more demanding 
standard than the United States alone. 3 

Awareness of this macroscale (and, initially, counter- 
intuitive) result grew gradually on both sides of the 
border in the late 1970s, along with the gap itself. By 
1987, the difference in health spending had grown to 
nearly three percentage points of GNP — 1 1.2 percent in 
the United States and 8.4 percent in Canada. The obvious 
questions are “Why?” and “How?” — the sources of dif- 
ference in both an accounting and a policy sense — and 
“So what?” — what consequences flow from the divergent 
performance? Further research has targeted the cost dif- 
ferences in three major areas: costs of insurance adminis- 
tration, physicians’ fees, and the “intensity” of hospital 
servicing. 4 

Administrative costs of insurance. It was apparent 
from the outset to the designers of the Canadian plans 
that multiple, pluralistic insurers marketing a wide range 
of plans differing in depth and breadth of coverage 
would require a large “load factor” — the difference be- 
tween premiums collected and benefits paid — to cover 
those design, administration, and marketing costs. In- 
deed, the Royal Commission on Health Services specifi- 
cally mentioned the avoidance of these marketing and 
administration overheads as a significant advantage of a 
universal, comprehensive system. 5 By the late 1980s, 
after nearly a decade of “market forces” in U.S. health 
care, about one-half of one percent of GNP in the United 
States is accounted for by the excess costs (relative to the 



Canadian system) of paying for the reimbursement sys- 
tem itself. 

Uwe Reinhardt refers to this quantity as the “B- 
Factor” in American health care: the costs of a (largely 
private) bureaucracy that neither provides care nor sup- 
ports its provision. 6 This “sector” of the U.S. health care 
industry is a relatively recent development; in 1960, U.S. 
and Canadian costs for administration and prepayment 
were roughly similar. From the perspective of health 
care, this part of the U.S./Canada cost discrepancy 
represents pure waste motion — pushing around bits of 
paper rather than providing health care. (One might 
argue that it represents the purchase of “variety,” but that 
is another story — and not a very plausible one). 7 

Physicians’ fees. The next major difference between 
the two systems has been in the growth of physicians’ 
fees. In the United States (as in Canada before public 
insurance), these fees have consistently escalated faster 
than general inflation rates. For the past twenty years, 
the bilateral bargaining process in Canada has kept fees 
more or less level in real terms. 8 The interesting questions 
here relate to the ways in which physicians’ practice and 
billing patterns respond to either negotiated or inde- 
pendent fee-setting processes. 

In aggregate, utilization differences between the coun- 
tries appear small. Physicians in Canada have neither left 
the field nor emigrated; nor have they increased their 
billing rates to offset the effects of controls. 9 Contrary to 
U.S. experience under the economic stabilization pro- 
gram (ESP), the ongoing process of fee negotiation in 
Canada has resulted in overall expenditure control. 10 
Nor has it been associated with any shortages of person- 
nel or difficulties of access; doctor-to-population ratios 
in Canada are about the same as in the United States and 
growing about as fast. 

It appears that the relative control of physicians’ fees 
has operated primarily as an “incomes policy,” limiting 
the transfer of wealth from the rest of society to physi- 
cians, or, in Reinhardt’s terms, influencing “the alloca- 
tion of lifestyles to providers.” 11 Whether it has had any 
significant impact on styles and patterns of medical 
practice — the mix, as opposed to the overall volume, of 
medical activity — is an interesting question to which 
cross-border research might well contribute. Whether 
such fine-structure differences, if they should exist, would 
affect the health of our respective populations is a sub- 
stantially more difficult question. 

Hospital costs. The third major component of the 
cross-border cost differential, and the focus of the article 
by Newhouse, Anderson, and Roos, is the difference in 
hospital costs. In 1985, these were estimated at $167.2 
billion, or 4.18 percent of GNP, in the United States. 12 
The corresponding estimate for Canada was 3.48 percent 
of GNP, nearly 20 percent below the U.S. ratio. 13 This 
gap has emerged over the past two decades; in 1971, 
hospital expenditures were actually a larger percentage 

of the Canadian GNP. 

Previous analyses of this component of the Cana- 
da/United States discrepancy have focused on the com- 
parison of trends within each country, rather than at- 
tempting to address levels of servicing directly. Alan 
Detsky showed that in Ontario, policies to limit the 
escalation of hospital costs had been successful but that 
their impact had been almost entirely on the “intensity of 
servicing” rather than on the escalation of costs of hospi- 
tal inputs. 14 The bundle of services — person hours of 
care, tests, procedures, drugs — received by patients in 
Ontario hospitals was rising less rapidly than in the 
United States. Indeed, over the period studied it hardly 
rose at all. Wages and other input costs, however, were 
rising about as fast (relative to general inflation rates) as 
in the United States. 

Similar findings were subsequently reported for the 
whole of Canada. 15 When expenditures per capita are 
deflated by an index of hospital input prices (wages and 
other things), the resulting “intensity measure” (which 
includes changes in both admissions or patient days per 
capita, and servicing rates per admission or patient day) 
has escalated much more slowly in Canada than in the 
United States, both after, and even before, 1971. (Public 
hospital, as opposed to medical, insurance was universal 
in Canada by 1961.) 

Since the expenditure differences in hospitals appear 
to be associated with real differences in servicing rates 
rather than simply bureaucratic overhead or fee levels, 
the question naturally arises as to whether the Canadian 
experience represents “underservicing” — the failure to 
provide patients with potentially effective interventions. 
Conversely, does the increasing “servicing intensity” in 
the American system reflect increasing provision of es- 
sentially ineffective services? 

Comparing Levels Of Expenditure 

Unlike previous investigators, Newhouse and col- 
leagues address the comparative levels of expenditure in 
each country. Carried through consistently, this ap- 
proach would permit the direct comparison of servicing 
intensities, rather than merely their rates of change. This, 
however, would require indices of hospital input prices in 
each country, which could be linked across the border at 
a point in time, rather than simply each set equal to 100.0 
in a common base year. 

Such comparative hospital input price data do not 
currently exist. Instead, the authors have taken per cap- 
ita hospital expenditures in each country’s own currency, 
converted the American series to 1985 dollars by using 
the gross national expenditure (GNE) consumption de- 
flator, and then converted the Canadian series to U.S. 
dollars by using the exchange rate in each year. The 
floating exchange rate is assigned double duty, both 
converting currencies at a point in time and reflecting the 

VOLUME 53, NO. 3 


discrepancies in the two countries’ inflation rates over 

Unfortunately, the procedure fails, for two reasons. 
First, the Canada/ U.S. exchange rate has fluctuated 
widely over this period for reasons and in ways quite 
unconnected with relative inflation rates. Over some 
(undefined) long run, movements in exchange rates 
should reflect countries’ relative inflation rates; in North 
America and between 1981 and 1985, they have not. A 
better procedure would have been to adjust each coun- 
try’s per capita expenditure by its own price index, and 
then apply the OECD estimates of the purchasing power 
parity (PPP) exchange rate for 1985 to the two curren- 
cies. As it is, the time series estimates of Canadian hospi- 
tal expenditure presented in Exhibit 1 of the article are 

Second, if one is to compare servicing intensity, one 
must deflate by indices of hospital input prices. There is 
no reason to believe that such prices bear the same 
relationship to general consumer prices in each country. 
The authors’ procedure might serve instead to measure 
the relative amount of generalized purchasing power 
given up, in each country, to the hospital system, rather 
than the real volume of hospital services bought. But 
then, what has been gained over the percent-of-GNP 

In fact, however, the principal thrust of the article by 
Newhouse and colleagues is not affected by the problems 
in converting across currencies. The estimates in Exhibit 
1 are not used elsewhere, except in the very general sense 
that the Canada/ United States discrepancy is A Big 
Number, which is certainly true. But it would be unfor- 
tunate if their nice round “50 percent” figure were taken 
too seriously. It is clearly too large. The current dollar 
expenditures on hospitals per capita in the two countries 
in 1985 are $676 (U.S.) and $633 (Canadian) — a differ- 
ence of 6.8 percent. If $0.85 U.S. equals $1 Canadian, the 
OECD-estimated PPP exchange rate for that year, the 
differential is 25.6 percent — still A Big Number, but 
much less dramatic. A good deal more work is necessary 
to develop a reliable time series of comparative expendi- 
ture levels, whether in terms of general purchasing power 
or a fortiori in terms of real “servicing intensity.” 

The authors approach this Big Number with a combi- 
nation of utilization analysis and speculation, and it is 
the former that is the heart of their article. They focus on 
the population over age sixty-five, to exploit the Ameri- 
can Medicare database. Unfortunately, since as they 
point out the Canadian financial system does not track 
costs per patient, one cannot assume that the differential 
in costs for the entire population applies to the over- 
sixty-five subgroup as well. 

Comparing selected jurisdictions, they find that 
lengths-of-stay are substantially higher north of the 
border, and that there is no evidence of lower admission 
rates or less severe cases as measured by diagnosis- 

related group (DRG) indices. This comparative case-mix 
analysis is particularly interesting, and is the authors’ 
principal contribution. It reinforces the view that the 
Canada/ United States cost differential is located in pat- 
terns of servicing within hospitals, not in different pat- 
terns or rates of admission or discharge. 

Further Research Opportunities 

Length-of-stay differences. There remain a couple of 
important points for further research. First, the large 
difference in lengths-of-stay is quite worrisome. As the 
authors are aware, de facto long-term cases are much 
more likely to be included in acute care beds in the 
Canadian hospital system, for reasons solidly rooted in 
the differences in the financing system. They have tried to 
remove these cases, both by eliminating patients desig- 
nated as other than acute care and by trimming lengths- 
of-stay at sixty days. The adequacy of these adjustments, 
however, depends on the administrative arrangements in 
the particular jurisdictions studied. In British Columbia, 
which has been quite aggressive in moving de facto 
long-term cases out of acute beds, the average length-of- 
stay for acute patients over age sixty-five is about 9.5 
days (in fiscal 1985-1986). 

Further work is clearly necessary to ensure that the 
Canadian data are not still “contaminated” by nonacute 
cases. This is of particular importance, since servicing 
intensity tends to be negatively correlated with length-of- 
stay. The increasingly divergent trends in intensity in the 
two systems, found by other researchers, no doubt reflect 
in part the increasing proportion of the Canadian acute 
hospital workload that is (however labeled) long-term 
care. 16 

Measuring “intensity.” The second major point is that 
“intensity” measures different things in the two systems. 
The complex payment system in the United States re- 
quires hospitals to maintain a much larger administra- 
tive and financial staff to bill patients and insurers, 
determine eligibility, and cope with disputes. The de- 
mands of “competition” are adding to the costs of mar- 
keting the hospitals’ products. These costs have no coun- 
terpart in the Canadian system and no obvious benefit to 
patients, although they are included in hospital expendi- 
tures rather than in the overhead costs of insurance and 
prepayment administration. 

The authors consider this point and reject it as a major 
contributor to the cost differential. Yet they quote David 
Himmelstein and Steffie Woolhandler, who provide a 
rough estimate of relative costs of administration in 
American and Canadian hospitals. 17 They estimate that 
in 1983, fully 10 percent of American hospital costs were 
“administrative waste” relative to what they might have 
been with a Canadian-style system. 

A possible source of confusion is that this figure is a 
share of American costs, whereas the “50 percent” differ- 
ential is on a Canadian denominator. Himmelstein and 



Woolhandler’s 10 percent represents not one-fifth but 
about 30 percent of the differential reported by New- 
house and colleagues. Furthermore, if the true Cana- 
da/United States differential is in fact closer to 25 per- 
cent, then the share accounted for by different internal 
administration costs is about half. No one has ever sug- 
gested that the whole differential was administrative, but 
half of A Big Number is also A Big Number. 

Relative administrative costs. Himmelstein and 
Woolhandler’s estimate is clearly a first cut, based on a 
number of diverse sources. But it matches, in order of 
magnitude, the impressions of hospital administrators 
with experience on both sides of the border. The authors’ 
dismissal of this issue is clearly wrong, and a much more 
detailed analysis of relative administrative costs would 
be well worthwhile. If we are concerned to use compara- 
tive experience to address questions of relative “under- 
funding” or “overfunding,” we presumably wish to com- 
pare the actual use of health care by comparable patients. 
Payments to accountants and public relations specialists 
(and even economists), as hospitals respond to the vagar- 
ies of the reimbursement system, are not part of this 

At the end of the day, however, all such aggregate 
comparisons can only be indicative, pointing beyond 
themselves. The authors’ call for more detailed studies of 
the actual process of care in the different systems, for 
similar types of problems, seems very clearly the right 
way to go, not least because such studies can be linked 
directly to comparative measures of outcomes. The 
answers at the aggregate level are already mostly in; it is 
time to look for God in the details. In the process, 
however, we must take particular care both to ensure 
that the patients studied are indeed comparable and that 
other forms of expenditure, unrelated to patient care, are 
not bootlegged into the comparison. 


1. S. Andreopoulos, ed., National Health Insurance: Can We Learn 
from Canada? (New York: John Wiley & Sons, 1975). 

2. T.R. Marmor, “Can the U.S. Learn from Canada?” in Andreopou- 
los, National Health Insurance; and J. Feder, J. Holahan, and 
T.R. Marmor, National Health Insurance: Conflicting Goals and 
Policy Choices (Washington, D.C.: The Urban Institute, 1980). 

3. A.J. Culyer, Health Expenditures in Canada: Myth and Reality, 
Past and Future (Toronto: Canadian Tax Foundation, 1988), 

4. M.L. Barer and R.G. Evans, “Riding North on a Southbound 

Horse? Expenditures, Prices, Utilization and Incomes in the Ca- 
nadian Health Care System,” in R.G. Evans and G.L. Stoddart, 
eds.. Medicare at Maturity: Achievements, Lessons and Chal- 
lenges (Calgary: University of Calgary Press, 1986), 53-163; and 
R.G. Evans, “Finding the Levers, Finding the Courage: Lessons 
from Cost Containment in North America,” Journal of Health 
Politics, Policy and Law (Winter 1986): 585-616. 

5. Royal Commission on Health Services (Hall Commission), Report, 
Vol. 1 (Ottawa: The Queen’s Printer, 1964), 745. 

6. U.E. Reinhardt, “On the B-Factor in American Health Care,” The 
Washington Post, 9 August 1988. 

7. R.G. Evans, “The Welfare Economics of Public Health Insurance: 
Theory and Canadian Practice,” in ed. L. Soderstrom, Social 
Insurance (Amsterdam: North-Holland, 1983), 71-103. 

8. M.L. Barer and R.G. Evans, “Prices, Proxies and Productivity: An 
Historical Analysis of Hospital and Medical Care in Canada,” in 
W.E. Diewert and C. Montmarquette, eds.. Price Level Measure- 
ment: Proceedings from a Conference Sponsored by Statistics 
Canada (Ottowa: Minister of Supply and Services Canada, 1983), 
704-777; and Barer and Evans, “Riding North on a Southbound 

9. M.L. Barer, R.G. Evans, and R.J. Labelle, The Frozen North: 
Controlling Physician Costs Through Controlling Fees — The 
Canadian Experience, monograph prepared for the U.S. Con- 
gress, Office of Technology Assessment, 1985; and M.L. Barer, 
R.G. Evans, and R.J. Labelle, “Fee Controls as Cost Control: 
Tales from the Frozen North,” The Milbank Quarterly 66, no. 1 
(1988): 1-64. 

10. J. Holahan and W. Scanlon, “Price Controls, Physician Fees and 
Physician Incomes from Medicare and Medicaid,” working paper 
no. 998-5 (Washington, D.C.: The Urban Institute, 1978); and J.R. 
Gabel and T.H. Rice, “Reducing Public Expenditures for Physi- 
cian Services: The Price of Paying Less,” Journal of Health Poli- 
tics, Policy and Law 9, no. 4(1985):595-609. 

1 1 . U.E. Reinhardt, “Resource Allocation in Health Care: The Alloca- 
tion of Lifestyles to Providers,” The Milbank Quarterly 65 (1987): 

12. U.S. Department of Health and Human Services, Health Care 
Financing Administration, “National Health Expenditures, 1986- 
2000,” Health Care Financing Review 8, no. 4 (1987): 1-36. 

13. Health and Welfare Canada, National Health Expenditures in 
Canada, 1975-1985 (Ottowa: Health Information Division, 1987). 

14. A.S. Detsky, S.R. Stacey, and C. Bombardier, “The Effectiveness 
of a Regulatory Strategy in Containing Hospital Costs: The Ontar- 
io Experience, 1967-1981,” The New England Journal of Medi- 
cine 309 (1983): 151-159; and A.S. Detsky et al., “Global Budgeting 
and the Teaching Hospital in Ontario,” Medical Care 24 (1986): 

15. Barer and Evans, “Riding North on a Southbound Horse?’ 

16. R.G. Evans et al., “The Long Goodbye: The Great Transformation 
of the British Columbia Hospital System,” Health Services Re- 
search (1989), forthcoming. 

17. D.U. Himmelstein and S. Woolhandler, “Cost Without Benefit: 
Administrative Waste in U.S. Health Care,” The New England 
Journal of Medicine 314, no. 7 (1986):441-445. 

VOLUME 53, NO. 3 


Perspectives: United States 

Learning From the Canadian Experience 


S OMETIME during the next decade the United 
States will probably embark on major reform of our 
pluralistic system of health care finance. The growth of 
the uninsured and the failure of the so-called competition 
revolution of the 1980s to stem the rise in health care 
spending are just two of the factors pushing the nation 
toward more radical change. 1 In seeking to develop new 
approaches, health policy experts inevitably will attempt 
to draw on the experiences of other countries, especially 
those such as Canada that have managed to implement 
universal coverage while simultaneously containing costs 
well below U.S. levels. 

In doing so, it would be wise to resist simplistic notions 
about the easy transfer of health care systems across 
national boundaries. “The organization of medicine,” 
law professor Walton H. Hamilton wrote in 1930, “is not 
a thing apart which can be subjected to study in isolation. 
It is an aspect of culture, whose arrangements are insep- 
arable from the general organization of society.” But 
even if it is impossible to reproduce another country’s 
experience, it should be possible to learn from it. The 
potential for learning is particularly great in a compari- 
son of Canada and the United States because of both the 
differences and the similarities between the two countries. 

In 1986, Canadians spent approximately 8.5 percent 
of their gross national product (GNP) on health care, 
while Americans spent approximately 10.9 percent. If 
U.S. spending had been held to the Canadian ratio, the 
savings would have amounted to about $ 100 billion. This 
large difference between Canada and the United States 
has emerged only since the 1970s. Before then, the per- 
centages of GNP spent for health care were similar in the 
two countries. This was not surprising because the Unit- 
ed States and Canada are similar in many respects, 
including training of physicians and other health profes- 
sionals, political and economic institutions, and popular 

VICTOR R. FUCHS is the Henry J. Kaiser, Jr. Professor of eco- 
nomics at Stanford University. He also is a research associate at the 
National Bureau of Economic Research, Inc., in Stanford, California. 

culture. Thus, the recent divergence in spending provides 
an unusual natural experiment. 

The exploratory study of hospital spending by Joseph 
Newhouse, Geoffrey Anderson, and Leslie Roos draws 
on that experiment to compare hospital utilization by 
patients age sixty-five years and over in the United States 
and Canada. Admission rates and case-mix indices ap- 
pear to be similar in the two countries; length-of-stay is 
much longer in Canada, but cost per case (and cost per 
enrolled person) is much lower. There is little reason to 
question the authors’ principal conclusions; therefore, I 
devote the balance of this commentary to certain concep- 
tual and analytical issues concerning international com- 
parisons of health care. 

Economic Accounting 

Newhouse and colleagues focus on the differential in 
expenditures per capita in U.S. dollars; they transform 
Canadian expenditures into U.S. dollars through an 
exchange rate. One possible problem with this approach 
is the determination of the appropriate rate. Most econ- 
omists believe that, in the long run, a free-market rate 
reflects differences in the price levels between the two 
countries (at least for internationally traded goods). In 
the short run, however, the market rate can be affected 
by capital flows, foreign exchange speculation, and other 
factors that are irrelevant to a comparison of health care 
systems. Use of an inappropriate exchange rate will dis- 
tort international comparisons. 

Consider, for instance, three possible comparisons of 
per capita expenditures for health care in the United 
States and Canada in 1980. 2 Basing a comparison on the 
market rate of exchange indicates that spending is 38 
percent higher in the United States. If the comparison is 
based on an exchange rate obtained by comparing the 
prices of all goods and services produced in the two 
countries (purchasing power parity, or PPP), the differ- 
ential is only 27 percent. A third possible comparison, 
based on an exchange rate derived from only health- 
sector prices (health purchasing power parity) shows a 
differential of only 22 percent. The fact that the third 



differential is smaller than the second indicates that, 
relative to other goods and services, health care prices are 
lower in Canada than in the United States. 

Sharp fluctuations in the Canadian/ U.S. market ex- 
change rate in recent years indicate that choice of the 
correct rate continues to be a problem of considerable 
practical significance. Between February 1986 and July 
1988, the number of Canadian dollars needed to pur- 
chase one U.S. dollar fell by 19 percent. In the first seven 
months of 1988 alone, the number of Canadian dollars 
needed to buy one U.S. dollar fell by 7 percent. The 
reasons for this appreciation in the value of the Canadian 
dollar are not known precisely, but probably have little 
to do with changes in health care. Nevertheless, compari- 
sons based on the market rate would show sharp fluctua- 
tions in the U.S./ Canadian differential in expenditures 
for health care. 3 

One way of avoiding the exchange rate problem is to 
concentrate on the differential in health care expendi- 
tures as a percentage of gross national product (-gnf), 
with each country’s values calculated in its own currency. 
This differential, in an accounting sense, must result 
from differences in one or more of the following three 
variables: the quantity of services per capita (t8f); the 
inputs required per quantity of service and the 

prices of health care inputs relative to GNP per capita 

(gnp ; pop ). That is, 

x o 1 P 


If we think of each term as the ratio of U.S. to Canada, 
the equation tells us that the U.S./ Canada ratio of the 
share of GNP devoted to health care is identically equal 
to the product of the three terms. Because the identity is 
multiplicative, the relationship between the logarithms 
of the U.S./ Canada ratios is additive. That is, 

gnp - l n pop + In cU In gnp ? pop 

Thus, it is possible in principle to decompose exactly the 
U.S./ Canada differential and to show how much is 
accounted for by differences in services per capita, differ- 
ences in productive efficiency, and differences in input 
prices (relative to GNP per capita). 

Behavioral Explanations 

A statistical decomposition along the lines outlined 
above would provide much useful information about the 
differences between the Canadian and U.S. health care 
systems. But it would be only a first step. Economic 
accounting needs to be supplemented by behavioral 
explanations. I believe that all three variables on the 
right-hand side of the equation contribute to the U.S./ 
Canadian differential, and it would be of tremendous 
theoretical and practical importance to understand what 
behavioral mechanisms are responsible for the national 
differences in those variables. 

Consider first the question of quantity of services per 
capita. If Canadians consume fewer services, what in the 
Canadian system constrains utilization? Some of the 

most popular explanations that have been offered with 
respect to U.S. health care expenditures fall flat if applied 
to the Canadian scene. For instance, Canadian patients 
are virtually fully insured; deductibles and coinsurance 
are clearly not the mechanism of restraint. Moreover, 
Canadian physicians are mostly reimbursed on a fee-for- 
service basis; there is very little use made of prepaid 
group practice, capitation, and other financial mecha- 
nisms that are relied on in the United States to restrain 
utilization by changing physician behavior. There are, 
however, government sanctions, actual or potential, that 
may cause Canadian physicians to limit their use of tests 
and other procedures. The most readily identifiable 
source of restraint on the Canadian scene is the fact that 
most of the funds for health care come from a single 
source. With hospital budgets set in advance, it is very 
difficult for hospital administrators, physicians, patients, 
or anyone else to spend more than the budgeted amount. 
A second potential source of restraint on utilization in 
the Canadian system is the much lower ratio of special- 
ists to general practitioners. By virtue of their training, 
knowledge, inclination, and interests, specialists tend to 
order more services. 

The smaller number of specialists in Canada also may 
contribute to the second term, namely, fewer inputs for 
any given volume of services. It is well known that in the 
United States the large number of surgeons and other 
specialists contributes to a low average workload. It is 
possible that workloads are higher in Canada; that is, 
highly trained health professionals may be used more 
efficiently. Canada also probably saves on the use of 
other personnel to enhance production efficiency. For 
instance, there must be many fewer people employed in 
health care in Canada to sell and administer insurance 
plans, and the Canadian system probably requires fewer 
employees for billing, utilization review, and other ad- 
ministrative and marketing functions. 

With respect to the third term, it seems likely that the 
Canadian provincial governments, with their monop- 
sony power in the purchase of medical care, can use that 
power to drive down the prices of inputs relative to the 
prices of other goods and services in Canada. This could 
show up in the prices paid to physicians, to drug compa- 
nies, and to other suppliers of goods and services. 


Economic accounting and behavioral explanations 
are two important elements in a comparison of the two 
health care systems. The third is to understand the con- 
sequences of differences in behavior. If Canadians receive 
fewer health services than Americans, what effect does 
that have on health or other aspects of well-being? Per- 
haps the services that are not received are of so little value 
to the patients that there are no discernible effects on 
mortality or morbidity. This question is, in principle, 
answerable, but there are others that will prove to be 
more difficult to investigate. Once one moves from fairly 
objective measures of health status to more subjective 

VOLUME 53, NO. 3 


questions about consumer satisfaction, the conceptual 
problems are quite severe. 

Consider, for instance, the problem of evaluating the 
differences in length-of-stay between the two countries. 
Is hospital output to be measured purely in terms of 
changes in medical status, or are amenities and conve- 
niences also to be considered? From an economic per- 
spective, the latter should be included if they are of value 
to the patient, that is, if the patient would be willing to 
pay something for them. When the length-of-stay differs 
appreciably, as it does between Canada and the United 
States, the conceptual problem is particularly perplex- 
ing, as can be seen from the following example. 

Suppose a Canadian patient and an American patient 
enter their respective hospitals with identical medical 
conditions, are treated successfully, and upon discharge 
their medical status is again identical. Further suppose 
that the Canadian patient stayed nine days and the 
American patient, six days. Shall we credit the hospitals 
with the same output? If change in medical status is the 
only criterion, the answer is obviously yes. But viewed 
from the patient’s perspective, the outputs need not be 
the same. If the patient values the extra three days in the 
hospital (that is, would be willing to pay something to be 
allowed to stay), the hospital with the longer stay should 
be credited with more output. On the other hand, if the 
patient prefers getting out in six rather than nine days 
(that is, would be willing to pay something not to have to 
stay the extra three days) the hospital with the shorter 
stay should be credited with more output. We know very 
little about the preferences of patients with respect to this 
question; furthermore, different patients may have dif- 
ferent preferences. 

It would also be interesting to know how the cost of 
producing an identical change in medical status varies 
with the length-of-stay. The longer stay may cost the 

hospital more because of additional expenses for room 
and board. On the other hand, it is also possible that the 
shorter stay costs more (to achieve the same medical 
condition at discharge) because services must be deliv- 
ered intensively. Moreover, since the two hospitals prob- 
ably will be using different combinations of inputs, the 
cost comparison may yield ambiguous results if the rela- 
tive prices of inputs differ in the two countries. Given a 
certain combination of preferences and relative prices, it 
may be more efficient for the American hospital to dis- 
charge after six days and more efficient for the Canadian 
hospital to discharge after nine. 

The differences in health care systems may have other 
consequences: for medical education, medical research, 
the recruitment of young women and men into medicine, 
and the like. A full comparison should consider these 
areas as well. In short, there is an enormous amount of 
work that could be done, and in my opinion should be 
done, to capitalize on the most interesting natural exper- 
iment in health care of recent decades: the different paths 
taken in Canada and the United States. 

Support for my research from The Pew Charitable Trusts is gratefully 


1. V.R. Fuchs, “The Counterrevolution in Health Care Financing,” 
The New England Journal of Medicine (30 April 1 987): 1 1 54- 1 1 56; 
and V.R. Fuchs, “The ‘Competition Revolution’ in Health Care,” 
Health Affairs (Summer 1988):5-24. 

2. U.S. Department of Commerce, Bureau of the Census, Statistical 
Abstract of the United States 1988 (Washington, D.C.: U.S. GPO, 
1988), 804; and Organization for Economic Cooperation and 
Development, Financing and Delivering Health Care: A Compar- 
ative Analysis of OECD Countries, Social Policy Studies no. 4 
(Paris:OECD, 1987), 21, Table 3. 

3. J.F. Burns, “Exchange Rate Keeps Canadian Industry on Pins and 
Needles,” The New York Times, 1 August 1988, C-8Z. 

Defending the U.S. Approach to Health Spending 


D ESPITE comparable admission rates and case- 
mix indices, the United States — according to 
Joseph Newhouse, Geoffrey Anderson, and Leslie Roos 
— spent 50 percent more per person over age sixty-five 
on hospital services than Canada in the early 1980s. The 
methodology they employed in arriving at this finding 
was meticulous and complete in its dedication to objec- 
tivity, and the necessary computational judgments seem 
reasonable. Consequently, the study results can safely be 
shifted from the category of hypothesis to the category of 
strong presumption. 

SAMUEL A. MITCHELL has been involved in a wide range of 
health policy activities for the past eight years in his capacity as research 
director for the Federation of American Health Systems. 

Reprinted with permission from the Winter of 1988 issue of Health 

The key inference of these findings is that “the differ- 
ence in hospital spending between the countries . . . must 
be accounted for primarily by differences in the cost of a 
‘case-mix unit’ per beneficiary.” The questions of main 
interest to policymakers are: (1) Why does this difference 
occur; (2) Is the difference “good” or “bad”; and (3) 
What, if anything, should be done? 

What Accounts For The Difference? 

Advocates of the Canadian system or, conversely, 
critics of the American system like to argue that the 
Canadian government’s monopsonistic control over 
health spending greatly minimizes the waste allegedly 
rampant in U.S. hospitals. This inference is facile and 



wrong, especially in the late 1980s when average hospital 
Medicare margins have been steadily declining and are 
expected to disappear in fiscal year 1988. 1 No hospital 
wants to lose money; thus it is unlikely that administra- 
tors, finding themselves under increasingly intense finan- 
cial pressure, have failed to do all they can to minimize 

A full analysis of why case-mix-adjusted hospital costs 
per beneficiary were so much higher in the United States 
should consider the following: ( 1 ) Wage differences exist 
among the two systems. Unfortunately, as Newhouse 
and colleagues note, the necessary data are not available. 
(2) There also are differences in the rate of development 
and diffusion of new technology. It would be very illumi- 
nating to look at comparative rates of lens implants, 
organ transplants, angioplasty, and the provision of 
state-of-the-art diagnostic procedures per 1 ,000 popula- 
tion. We would not be surprised if rates in the United 
States were significantly higher. (3) Differences exist in 
income and the income elasticity of demand. Americans 
on average are richer than Canadians; richer people tend 
to spend more of their marginal income in health care. 
Moreover, Americans’ income elasticity of demand for 
health care may be greater than that of Canadians. 

(4) The two cultures possess different values. The 
strong tradition in the United States of favoring the 
interests of the individual over those of society means 
that we condone, even insist upon, heroic measures to 
extend life or improve the quality of life, even if the likely 
improvement is slight and the long-term prognosis is 
impervious to treatment, no matter how elaborate. Thus, 
American physicians tend to fight disease, disability, and 
the prospect of death aggressively with every tool mod- 
ern technology makes available. The “fix the problem at 
all costs” approach produces an occasional miracle, but 
it is very expensive, and the incremental improvement in 
health status often is very slight while the cost often is 
very high. 

(5) Physician payment mechanisms differ as well. 
Physicians in the United States, for the most part, have 
been paid more for doing more, and the return on their 
time is higher if they perform a procedure than if they use 
their cognitive skills. Since procedures often require hos- 
pital care (more so during the time period covered by the 
study — 1981, 1984, and 1985 — than today), incentives 
favoring procedures translate into higher hospital ex- 
penditures. Canadian physicians, by contrast, during the 
years studied had less leeway to make more by doing 
more, thereby driving up hospital costs. They were oper- 
ating under a system of fee schedules and overall provin- 
cial limits on health spending. Moreover, extra billing of 
patients by physicians was relatively infrequent. In fact, 
as John Iglehart has noted, in 1984 the Canadian Parlia- 
ment unanimously passed legislation providing that “pro- 
vinces that imposed, or permitted physicians to impose, 
direct charges on patients would lose federal grants dol- 
lar for dollar in proportion to such charges.” 2 

The relative importance of these and other factors 
accounting for differences in hospital spending per com- 
parable case is not known, but it does seem reasonable to 
argue that the simplistic notion that the American hospi- 
tal system is much more wasteful, as its critics contend, is 
at best misleading. An appreciation of the values and 
incentives affecting physician decision making, which in 
turn importantly affect hospital costs, is a prerequisite 
for developing payment policies that best serve the Amer- 
ican public’s interest. 

Assessing The Differences 

Newhouse, Anderson, and Roos obliquely address the 
question of whether the U.S./ Canadian differences are 
“good” or “bad” when they say that “the question (of 
what, if anything, the United States buys with the addi- 
tional intensity of care) can best be addressed with data 
that pertain to outcomes.” We do not know how out- 
comes in the United States and Canada compare. How- 
ever, even if there is no difference in measurable out- 
comes such as mortality rates, life expectancy, prevent- 
able treatment errors, and so on, there are other impor- 
tant but perhaps impossible-to-measure components of 
value that must be considered as well. To an individual 
patient, an extra dollar of hospital care spent in his or her 
behalf may not improve the ultimate outcome, but still 
could have great value if treatment did nothing more 
than increase comfort, reduce anxiety, enhance the abil- 
ity to function independently, or reduce, even slightly, 
the probability of an adverse outcome. Americans may 
not live longer than Canadians, but our expensive health 
care system may enable those who have been ill to live 
better. And it may offer valuable assurances to those of 
us who are not patients, but could be, that top-of-the-line 
care will be available to us immediately on demand. In 
short, before reaching conclusions about the value of 
hospital care relative to the cost, it is necessary to con- 
sider all elements of satisfaction as perceived by both 
actual and potential patients. The ultimate test of the 
“goodness” or “badness” of American versus Canadian 
hospital spending levels should, I believe, turn on which 
process for arriving at expenditure decisions best reveals 
the value of hospital care not just to those who happen to 
be patients, but to the rest of us as well. 

The problem of maximizing satisfaction relative to 
cost is immensely complicated by the fact that the same 
person’s preferences differ, depending on whether that 
person is a particular beneficiary of the health care 
system — a patient — or an anonymous financier of health 
care either as a taxpayer or a consumer of goods and 
services, part of whose cost is the cost of employee health 
care. Because so much hospital care is paid for by a third 
party, the usual measure of consumer perceptions of 
value relative to cost— the price the beneficiary of a 
service is willing to pay — is not a useful guide to measur- 
ing satisfaction relative to cost. Since beneficiaries typi- 
cally do not pay the bills, they are largely indifferent 
about how large the bills are. The fundamental policy 

VOLUME 53, NO. 3 


issue, then, is this: if the pricing process that occurs 
between buyers and sellers in a properly functioning 
market is not available, what other mechanism will best 
reveal those cost/ service tradeoffs that maximize satis- 
faction per dollar spent? 

Alternatives For Action 

Canada has decided that government monopsony is 
best. Power to set overall spending limits is concentrated 
in the hands of government experts. Budget-setting offi- 
cials are only very remotely accountable for the effects of 
their decisions on individual patients, but the effects of 
their decisions on government spending are highly vis- 
ible. Thus, over time, the interests of the public as tax- 
payers will dominate. Because feedback as to the conse- 
quences of their decision is slow and indirect, and there 
are few incentives to maximize satisfaction, I question 
whether centralizing decision-making authority over 
total spending is the best possible way of revealing what 
level and mix of spending creates the greatest satisfaction. 

On the other hand, the United States, with its tradition 
of favoring the immediate interests of the individual at all 
costs, has tried to avoid altogether the problem of mak- 
ing painful choices between controlling costs and giving 

individual patients the best of everything. The consensus 
now, however, is that we no longer have this luxury. 

I believe that for the United States there is a better 
alternative than adopting the monopsonistic Canadian 
system. The decentralized American payment system is 
more in keeping with the high value Americans put on 
holding payers accountable to the wishes of the insured. 
However, it heretofore has lacked the essential ingre- 
dient for striking the right balance between accommo- 
dating the wishes of patients and keeping costs within 
the constraints set by whoever is paying the bills. This 
missing ingredient is information as to what works 
(effectiveness) and information at the local level as to 
which providers not only do the right things, but do them 
most efficiently. Newhouse, Anderson, and Roos have 
given us a solid base of comparative data, but it should 
not be inferred from their findings that the Canadian 
system is better or that the United States should adopt 
similar payment mechanisms. 


1 . A. Dobson, “Letter to the Honorable Martin Frost” (Washington, 
D.C.: Consolidated Consulting Group, 25 August 1988). 

2. J.K. Iglehart, “Health Policy Report: Canada’s Health Care Sys- 
tem,” The New England Journal of Medicine 315, no. 3(1988):207. 

Fixing an Inefficient System 


N O observer of the American health care delivery 
system should be surprised by the results of the 
study by Joseph Newhouse, Geoffrey Anderson, and 
Leslie Roos on trends in hospital spending in the United 
States and Canada. Their conclusions confirm our sus- 
picions that it is possible to manage health care delivery 
more efficiently without impairing quality. 

The author’s key findings support four critical conclu- 
sions about the American health care delivery system: 
(1) Contrary to the contentions of the hospital industry, 
U.S. hospitals are, on the whole, very generously sup- 
ported. (2) TheU.S. hospital system is inefficient. (3) The 
higher costs associated with hospital care in the United 
States are making universal coverage of our population 
difficult to achieve. (4) Substantial economies remain 
possible without fear of affecting outcomes. 

The U.S. hospital system is generously supported. We 
devote 4.4 percent of gross national product (GNP) to 
hospital care, while Canada and the Federal Republic of 
Germany devote only 3.5 percent and 2.7 percent, respec- 

FORTNEY H. (PETE) STARK is a Democratic representative 
from California’s Ninth District. He is chairman of the U.S. House of 
Representatives Ways and Means Subcommittee on Health. In fall 
1988, he and his staff traveled to Canada to gain firsthand information 
about the Canadian health care system. 

Reprinted with permission from the Winter 1988 issue of Health 

tively. Yet there is no evidence that the Canadians and 
the West Germans do not have high-quality systems, 
and, in fact, their mortality statistics are better than those 
of the United States. 

The U.S. hospital system is still an extremely ineffi- 
cient industry. On a given day, there are 349,146 empty, 
staffed hospital beds in this country — over a third of the 
total staffed beds. If we add the beds that are built but not 
staffed, almost half the beds in this country are unused. 
In addition to empty beds, virtually every city boasts 
underused specialized services, such as cardiac surgery, 
where not enough work is done to maintain competency. 
And because of this amount of waste we face an approx- 
imate 1 1 percent increase in hospital capital costs year 
after year. 

Canada, on the other hand, enjoys a hospital occu- 
pancy rate of 84 percent. The reason for this significantly 
higher rate is clear. The Canadians do not hand their 
hospitals a blank check and allow them to build facilities 
whether they are needed or not, as do we. Canada estab- 
lishes a capital budget each year at the provincial govern- 
ment level and carefully plans how to allocate resources 
within that budget so that each community has the 
health care facilities that it needs and that the nation can 




The opportunity costs associated with the higher level 
of expenditures per hospital admission in the United 
States are substantial. Most importantly, if our expendi- 
tures were more in line with the Canadians’, we could 
afford coverage for those who lack health insurance. All 
Canadians have health insurance. In the United States, 
thirty-seven million Americans are uninsured, and an- 
other seven to ten million are inadequately covered. 
Two-thirds of uninsured Americans are full-time workers 
or their dependents. The inadequacy of our health insur- 
ance system has resulted in a gross maldistribution of 
resources in American hospitals. Our present financing 
system is assuring that the rich get richer and the poor get 

Hospitals that serve those covered by private health 
insurance and Medicare are overfunded, while those 
serving the poor are underfunded. The affluent hospitals 
can afford to purchase the latest technology and to 
renovate their facilities regularly. Meanwhile, the public 
and private hospitals serving the poor are falling behind 
and falling apart. Our response to the current situation 

must focus on the goal of assuring access to needed 
services on a cost-effective basis. The study by Newhouse 
and colleagues makes clear that we need not raise public 
and private payments to hospitals at excessive rates 
simply because hospitals continue to spend themselves 
into tight financial situations. In fact, given the ineffi- 
ciency of the system that this article highlights, further 
cuts can safely be made if the cuts are targeted to the 
inefficient parts of the system. For example, we can 
reduce the rate of growth in capital payments and reduce 
payments for support of teaching programs that are 
training specialists the country does not need. 

The Canadians view health care as a service to which 
every member of society must have access. In contrast, 
many in our society see health care primarily as the 
buying and selling of a commodity by independent enti- 
ties. As I see it, the Canadian perspective is more appro- 
priate. The list of unmet health needs in our nation is a 
long and disgraceful one to which we must find ways to 
respond. The Canadian success in holding down costs 
while providing universal access offers a lesson for all. 


The Officers and Directors of the Auxiliary to Connecticut State Medical Society 
cordially invites your spouse to support organized medicine by 
participating in the varied activities of the auxilliary. 

If you wish your spouse to receive membership information, 
please phone the Connecticut State Medical Society. 

Phone 865-0587 

VOLUME 53, NO. 3 






























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Guest Editorial 

Residency Requirements in Medicine 
and the Community Hospital 

With the recent passage of new residency require- 
ments for accreditation in internal medicine and its sub- 
specialities, we are entering a new era in the role of the 
community hospital in internal medicine education and 
training. For many years the community hospitals have 
played a major part in training internists to enter the 
private practice of internal medicine and to be the deliv- 
erers of “primary care” to the communities they serve. 
The new accreditation requirements relate to the milieu 
that should exist in teaching hospitals. They include the 

• that the institution demonstrate educational and re- 
search activities equivalent in quality to those charac- 
teristic of academic medical centers affiliated with 
LCME-accredited medical schools; 

• that the program director be a full-time institutional 
appointee and that there must be at least four addi- 
tional full-time faculty members who dedicate sub- 
stantial effort to the training program; 

• that a qualified individual, preferably full-time, should 
be responsible for teaching activities in each of the 
recognized specialities; 

• that at least two additional accredited residencies be 
sponsored by the institution; 

• that the teaching responsibilities of residents must not 
involve students who require special remedial work 
and extensive supervision, as may be the case with 
students from medical schools not accredited by the 

• that special care unit experience should not exceed six 
months in three years of training; 

• that the performance of its graduates on the certifying 
examination of the American Board of Internal Medi- 
cine may result in a loss of accreditation for the pro- 
gram if the pass rate of the program’s graduates on 
examination for a recent defined three-year period is 
less than 50%, or fewer than 75% of those completing 
their training in the program taking the examination. 
In the subspecialties, additional requirements for full- 
time direction of a program offering a fellowship as 
well as existence of three or more fellowship programs 
and clinical research are requirements. 

It is clear that these requirements are directed toward 
removing accreditation from a large number of pro- 

Editorials are expressions of personal opinion and do not 
necessarily reflect the policies of CSMS. 

Connecticut Medicine does not hold itself responsible for 
statements made by any contributor. 

grams that utilize residents for fulfilling the service re- 
sponsibilities in the hospital. It also becomes clear that 
the affiliating university must play a major role in the 
community hospitals that it wishes to support. 

The first and most important requirement in this new 
relationship is for the university to decide if it wishes to 
involve itself with community hospitals. If the answer to 
this question is affirmative, the university must define 
this relationship, which may represent one of several 
models. In one model the university may integrate the 
community hospital into its training program and rotate 
its residents to the community hospital for an experience 
that may be unavailable in the medical center setting. 
Such experiences might include general medical service 
rotations, as well as continuity clinics or primary care 
office rotations. An alternative would be for the medical 
school to lend academic support to the community hos- 
pital and assist in the definition of a curriculum in that 
hospital. Further, by assisting the community hospital in 
recruitment of residents and then permitting those resi- 
dents to rotate to the medical center for experiences 
unavailable to them in the community hospital, the uni- 
versity would be demonstrating a large measure of sup- 
port and commitment. 

One clear issue that remains to be recognized by the 
university is that the continuity of care and primary care 
experiences in the community can be far more meaning- 
ful than those the resident can acquire in the tertiary care 
medical center setting. It should be the university’s re- 
sponsibility to work with the faculty based at the com- 
munity hospital to organize and coordinate, through a 
well defined curriculum, the way in which this role can be 
fulfilled by the community hospital. 

Another key point in defining the relationship between 
the university and the community hospital relates to the 
identification of faculty. If the medical school does not 
recognize that there are physicians in the community 
hospital with a true commitment to teaching, clinical 
research, and patient care, and is not prepared to reward 
those individuals with appropriate academic appoint- 
ments, then it is highly unlikely that the relationships 
between the two institutions will be successful. 

An additional, and perhaps the most critical compo- 
nent, involves the responsibilities of the administration 
and the board of trustees of the community hospital. The 
era that we are entering requires that they reaffirm their 
commitment to the value of the teaching program to the 
hospital. Without the active support of both administra- 
tion and trustees, the medical staff will soon become 
disenchanted with the hospital’s role in teaching. There 
must be a commitment for financial support that is active 
and ongoing if teaching programs are to continue to 

VOLUME 53, NO. 3 


thrive with these new requirements being placed on them 
by regulatory agencies, as well as the new difficulties in 
funding. I believe we will see many community hospitals, 
after careful introspection, abandon their teaching activ- 
ities. This has some negative consequences including a 
lack of staff renewal in some communities, a delay in the 
transfer of technology and information from the medical 
center to the community hospital, and, most impor- 
tantly, a decline in the quality of care for the patients 
being served. It is our responsibility as educators and 

program directors to be sure that our medical staff, 
administration, trustees, and the community which we 
serve understand the implications of these new require- 
ments and the demands that they will place on our 

Michael L. Friedland, M.D. 

Chairman, Department of Medicine, 

St. Vincent’s Medical Center, Bridgeport; 

Professor of Clinical Medicine, New York Medical College, 

Valhalla, NY 

50 Years Ago 

From the Journal of the Connecticut State Medical Society 

March 1939 

A Full Time Secretary 

At its Annual Meeting in May 1936 the House of 
Delegates of the Connecticut State Medical Society took 
a step which will long remain as an outstanding evidence 
of progress. It had been apparent to many in the Society 
for a few years prior to that date that there was a need for 
more assistance in the administrative work of the Society. 
The so-called radical, progressive element advocated a 
full time secretary with sufficient office assistance to cope 
properly with the increasing problems confronting or- 
ganized medicine in the State. The more conservative 
reactionary members opposed any such change and were 
content to carry on with a part time member Secretary 
doing the work as best he could and where best he could. 
After the situation had been carefully studied by a special 
committee appointed by the President, a compromise 
plan was proposed and accepted by the House of Dele- 
gates. By this plan there were established three Secretar- 
ies, one of these being an Administrative Secretary, who 
would be a member of the Society on a part time basis, 
with an office equipped with a full time stenographer. 
The remainder of the Secretarial triumvirate included a 
Legislative Secretary and a Secretary on Scientific Work 
to act as Editor of the Journal. 

This suggested change in administrative personnel was 
accepted by the House of Delegates and an increase in 
annual dues from four to five dollars followed. The new 
encumbent of the office of Administrative Secretary was 
our present Executive Secretary, Dr. Creighton Barker. 
The duties of this secretary have increased like the 
proverbial snowball and following the annual meeting of 
the Society in June 1938 we find him assuming, in addi- 
tion to his other duties, those of Legislative Secretary. In 
the three years the work of the Executive Secretary’s 
office was likewise increased beyond the conception of 
most of the members so that at the present time there are 
required in that office two full time stenographers as well 
as additional assistance at certain periods of the year. 
The budget of the Society, to keep pace with the require- 

ments of the administrative needs and of the monthly 
Journal, has been increased from $7,125.00 for the year 
1936-1937 to $12,500.00 for the year 1938-1939. All this 
is in keeping with changes in the practice of medicine and 
in the proper administration of the duties which organ- 
ized medicine has found itself obligated to assume 
throughout the entire country. It is not a question of how 
cheaply a State Medical Society can be managed today 
but of how efficiently it can carry on for the best interests 
of its membership. For several months it has been appar- 
ent to many who are cognizant of the facts that the 
demands made upon our part time Executive Secretary 
are such that it is physically impossible for one individual 
to meet them and at the same time pursue a private 
practice. His duties carry him far afield, for beside fre- 
quent trips to Hartford to attend hearings on bills perti- 
nent to the practice of medicine or speaking in Bridge- 
port, Hartford, Waterbury and New London on the vital 
issues of medicine as they exist today, he is called to 
National Medical headquarters in Chicago, or to Fed- 
eral headquarters in Washington. His ear must be ever 
on the ground and his finger on the pulse to detect every 
move in this swiftly changing order. If medicine is at the 
cross roads, as Dr. Van Etten, former speaker of A.M. A. 
House of Delegates say it is, such an office or person is 
indispensible for the state organization and its individual 

In many State Medical societies where there is large 
membership there will be found a full time secretary who 
receives a recompense commensurate with his services. 
Our Society must take a similar step if it is to continue to 
develop as it has during the last three years. Therefore, 
the Council is considering that the budget be increased to 
care for these needed developments. However, the ulti- 
mate decision must rest with each member through the 
component County Associations and through the House 
of Delegates of the State Society. 

The Editor 
Stanley B. Weld, M.D. 



of the 


May 10, 11, 1989 
Ramada Inn 
275 Research Parkway 
Meriden, Connecticut 


James D. Kenney, M.D., New Haven, Chairman 
Dennis L. Bordan, M.D., Bridgeport 
John M. Gibbons, M.D., Hartford 
Julia B. Sabetta, M.D., Westport 


The 197th Annual Meeting of the Connecticut State Medical 
Society is planned for May 10th and 1 1th this year. The House of 
Delegates will meet on Wednesday, May 10th in an all day session. 
The progressively more difficult issues facing medicine today will 
be addressed including such timely subjects as RBRVS, AIDS, 
Universal Healthcare, and the incremental incursion of limited 
licensed practitioners into the practice of medicine. Updates on 
CMIC, M.D. Health Plan, and CPRO will be presented. Any 
interested physician members may attend and speak at reference 
committee hearings as well as observe the very democratic action 
of the House of Delegates as it comes to grips with these thorny 
issues. I believe it is a great learning experience for any physician 

Included at the House of Delegates meeting will be the inaugura- 
tion of our next president, Roger S. Beck, M.D. of Hartford, 
whose address should give us further direction for the year to 
follow. A reception in Dr. Beck’s honor will be held at the close of 
the House of Delegates. 

On Thursday, May 1 1th, the sections will meet both morning 
and afternoon with their own programs. For anyone interested, an 
intriguing 10:30 A.M. program on the burgeoning “transplanta- 
tion industry” will be presented. Dr. William Marks, Associate 
Professor of Surgery from the Transplantation Unit at Yale, will 
discuss the growth of transplantation services, their distribution 
and cost, and their integration into the fabric of medical practice. 
Dr. Robert Levine, Professor of Medicine and Chairman of the 
Human Investigation Committee at Yale, will discuss some of the 
ethical and social issues which derive from the practice of trans- 
plantation of tissues. This session will be followed by a luncheon. 
Please utilize the appropriate tear outs and take advantage of what 
I feel is one of the many important benefits provided by your 

Norman A. Zlotsky, M.D. 



The registration desk will be located in the lobby of the Inn 
and everyone attending the meeting is requested to register. 
There will be no charge for registration. 


There are ample parking facilities 


Telephone messages will be received at Meriden, 238-2380. 


Luncheon will be served Poolside. MEMBERS OF THE 
VANCE RESERVATION ONLY. If you plan to attend 
the luncheon, it is the utmost importance that the card 
enclosed with the program be returned at once. 


Persons who wish to stay overnight at the Inn should make 
room reservations as soon as possible. Please indicate in 
your letter that you are attending the Connecticut State 
Medical Society Meeting. 


The House of Delegates will be held on May 10th and the 
scientific program will be concentrated in one day, May 
11th. The general program will be held in the ballroom 
between 10:30 A.M. and 12:30 P.M. and the section meet- 
ings will be held in the morning and afternoon in the rooms 
listed in the program. 


The inauguration of the new President will take place at the 
House of Delegates meeting on May 10th, at about 3:00 
P.M. All members are invited to attend the inauguration. A 
reception for the President will be held immediately follow- 
ing the close of the meeting. 


All the exhibits will be located in one section of the ball- 
room. Physicians should take advantage of the opportunity 
to review what is new and timely by visiting the commercial 



VOLUME 53, NO. 3 



WEDNESDAY, MAY 10, 1989 


Kenneth M. Robbins, M.D., Middletown, Speaker of the House 
Sultan Ahamed, M.D., Norwich, Vice Speaker of the House 




Jerald R. Schenken, M.D., Omaha, Nebraska, Member, 
Board of Trustees, AMA 



Norman A. Zlotsky, M.D., Rockville 
Roger S. Beck, M.D., Hartford 

THURSDAY, MAY 11, 1989 




(Listing elsewhere in program) 


President, Connecticut State Medical Society 


James D. Kenney, M.D., New Haven, Chairman of the Com- 
mittee on the Program of the Scientific Assembly 

Associate Professor of Surgery (Transplantation), Yale 
University School of Medicine 



fessor of Medicine and Chairman of the Human Investi- 
gation Committee, Yale University School of Medicine 







8:30 Jericho Room 

President: Jeffrey N. Alter, M.D., Waterbury 
Secretary: Robert D. Greenberg, M.D., Vernon 



Clinical Professor of Dermatology, New York Medical 
College, Valhalla, New York 


8:30A.M. Arlington Room 

President: Karl R. Friedmann, Old Lyme 
Secretary: Nelson C. Walker, II, M.D., Storrs 




8:30 A.M. Brunswick Room 

President: Brett J. Gerstenhaber, M.D., New Haven 
Secretary: Andrew C. Wormser, M.D., New Haven 

ciate Clinical Professor of Medicine, Yale University 
School of Medicine 


Clinical Professor of Medicine, Yale University School 
of Medicine and UConn School of Medicine 



9:00 Ivoryton Room 

President: Jan H. Mashman, M.D., Danbury 
Secretary: Arthur M. Seigel, M.D., New Haven 


Professor of Neurology, Department of Neurology, Uni- 
versity of Connecticut School of Medicine 


8:30 A.M. Fairfield Room 

President: John W. O’Brien, M.D., New Haven 
Secretary: Mary Ita Malone, M.D., Middletown 


stitute of Rehabilitation, New York University School 

of Medicine 



4:00 P.M. Regency Room 

President: Jonathan D. Katz, M.D., Bridgeport 
Secretary: Vacancy 


RYAN COOK, M.D., PITTSBURGH; Professor of Anes- 
thesiology, Children’s Hospital of Pittsburgh 



6:30 Renaissance Room 

President: Anthony V. Piccirillo, M.D., Wallingford 
Secretary: Jeffrey D. Miller, M.D., Danbury 


NEW HAVEN; Professor of Dermatology, Yale University 
School of Medicine 


2:30 Jericho Room 

President: John N. German, M.D., New London 
Secretary: Isaac Goodrich, M.D., New Haven 

of Neurosurgery and Chief of Surgery, Yale University 
School of Medicine 

3:30 Arlington Room 

President: Samuel G. Smith, M.D., Manchester 
Secretary: Stanley R. Lavietes, M.D., New Haven 


Associate Director, Department of Professional Liability, 
American College of Obstetricians and Gynecologists 



2:30 Danbury Room 

President: Dennis G. O’Neill, M.D., Manchester 
Secretary: Irwin Nash, M.D., New Haven 


Pathologist, UConn Health Center 

2:30 Fairfield Room 

President: Steven A. Hirshom, M.D., Bridgeport 
Secretary: Charles E. Littlejohn, M.D., Stamford 


Vincent’s Medical Center Bridgeport 


2:30 P.M. Guilford Room 

President: James F. Walsh III, M.D., Bridgeport 
Secretary: Haik K. Kavookjian, M.D., Stamford 




As an organization accredited for continuing medical edu- 
cation by the Affiliation Committee for Continuing Medi- 
cal Education, Yale University School of Medicine certifies 
that this program is acceptable for Category I credit as 
specified by the American Medical Association for the 
Physicians Recognition Award. Credit is granted in this 
category on an hour for hour basis. 


The Commission on Education of the A AFP has accredited 
the scientific program of the Society’s Annual Meeting for 
two hours of prescribed credit for the general lecture and 
one and one half hours of elective credit for each lecture attended 
which is presented by the individual specialty sections of the 


The following section of the Society will not be meeting on May 1 1 . 
Following is the date and location of the meeting: 

MAY 18, 1989 

4:00 Ramada Inn, Meriden 

President: Malcolm S. Edgar, Jr., M.D., Norwich 
Secretary: Gerard J. Lawrence, M.D., Willimantic 
Director, Washington Office of American Academy of 
Orthopedic Surgeons 


Our exhibits contribute to the value of our assembly by 
presenting goods and services of interest and importance to 
physicians. Personal visits to the booths will increase your 
understanding of the materials and programs on display. 

Ayr Insurance Agency, Hamden, Connecticut 
Blue Cross-Blue Shield of Connecticut, North Haven, Connecticut 
Brentwood Instruments Incorporated, Torrance, California 
Connecticut Medical Insurance Company, (CMIC), North Haven, 

Dodson Insurance Group, Kansas City, Missouri 
Eli Lilly & Company, Indianapolis, Indiana 
Forty-Seven Medical Equipment Corporation, New York, 
New York 

Gaylord Hospital, Wallingford, Connecticut 
Merck & Company, West Point, Pennsylvania 
Safeway Disposal System Incorporated, Middletown, Connecticut 
Travelers Insurance Company, Wallingford, Connecticut 
Wertheim Eilers Associates, Incorporated, Hartford, Connecticut 

The Boehringer-Mannheim Diagnostic Company will provide 
free cholesterol screening on the Reflotron machine in the exhibit 

The Connecticut State Medical Society acknowledges with thanks 
an educational program grant received from: 

Geigy Pharmaceuticals, Summit, New Jersey 

VOLUME 53, NO. 3 




The President’s Page 

RBRVS: Continued 

As promised earlier, this President’s Page will highlight the 
Resource Based Relative Value Scale activity in the past three 
months. The extraordinary outcome of the debate at the AMA’s 
Semi-Annual Meeting was the unity shown by all groups involved. 
While a significant list of modifications was recognized as neces- 
sary, the diverse specialty groups still looked to the AMA as 
medicine’s voice in this endeavor, though all may provide input 
where needed. 

In the meantime, the Physician Payment Review Commission 
(PPRC) has begun its hearings in preparation for reporting to 
Congress its recommendations for financing Medicare. The Com- 
mission members recognize that they must control volume to be 
effective, something which the RBRVS per se does not do. 

One direction is to develop parameters for appropriate care and not to pay for inappropriate 
care. Many groups, including the PPRC, the Prospective Payment Assessment Commission 
and specialty societies, are working in this area. Some central body with Solomonic intelligence 
will be needed to turn such information into a volume control, while recognizing that medical 
care is a continually evolving process, that regional differences are possible with similar 
percentages of good outcomes, and that quality could be hurt by too rigid an interpretation of 
such parameters without due process review by physician peers. In other words, the whole 
process is becoming more and more complicated, as expected. 

RBRVS problems are seen in the variations in coding practices: for example, whether a 
surgical procedure is bundled into a global code or broken down into pre- and postoperative 
segments as well as individual parts of the procedure. No handle on costs will be possible until 
such a global fee can be developed not only for surgical procedures but also, for example, for 
what constitutes a periodic check-up for a 70-year-old patient. 

Other volume controls that PPRC is looking at are expenditure controls for physicians. Such 
controls would be based on data showing the growth and aging of the elderly population, 
changes in prices of services, and service utilization in an area. Fee updates would depend on 
whether expenditures for an area stayed within the targeted range. Detailed policy has not yet 
been developed as recommended, but the PPRC may attempt with expenditure targets to make 
physicians more responsible for appropriate use of services and for decreasing the government’s 
role in the process. This coincides with the ideas of Dr. Roper, Administrator of the Health Care 
Financing Administration (HCFA), who would like to capitate Medicare on a regional basis by 
providing a specific lump sum for all medical services. 

With all this actually going on, there are no answers now on what medical reimbursement will 
ultimately look like. PPRC expects 1991 to be the earliest possible date for implementation of a 
modified resource based fee schedule. Our AMA delegates are very much aware of your interest 
as they monitor the deliberations. Appropriate action items will be brought to the CSMS 
Council and House of Delegates as they arise, and we will look to those who have special interest 
and expertise to help us provide input to the AMA. 

Norman A. Zlotsky, M.D. 


VOLUME 53, NO. 3 


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Reflections on Medicine 

Telling the Tall Tales 


The Guns of August was the first of Barbara Tuch- 
man’s books that I read. For our generation the Great 
War had been our fathers’ war, and we had grown up 
with the memory of it; our war was yet to come. The 
movies we liked, the patriotic songs, many popular sto- 
ries, novels, and much of the poetry had the flavor of 
1914-18. When we came to learn something of the official 
history from our high school textbooks, just before the 
last chapter on the 1928 election and the Depression, we 
added little to the words we already knew: Sarajevo, the 
Somme, the Lusitania, Pershing, the Kaiser, and Wood- 
row Wilson and the League of Nations, a few names and 
places to associate with the old twice-told tales. It took 
the skillful storytelling of Barbara Tuchman to make us 
feel that we, 30 years later in 1962, now understood the 
real history of that war. 

Historians said she did not always get it quite right, 
but we paid little attention to them. More books fol- 
lowed and we did not stop reading Barbara Tuchman 
even after we heard that she had not earned a profes- 
sional degree in history, and during the past few months 
we hoped that The First Salute would not be her last 
book, but it turned out to be just that. Now we shall need 
another good amateur historian with a talent for word- 
craft, just as the theologians have needed the great 
preachers and the scientists have needed the good science 
writers. If scholars are to write only for other scholars, 
and they must, and yet not have their interpreters, then 
the rest of us are left to ignorance and folly, understand- 
ing, as we do, only the vernacular, the blind leading the 

Recently I was displaying my amateur knowledge of 
the origins of the alphabet by drawing an upside-down 
A and showing that it had begun as a picture of a cow’s 
head, called aleph in Hebrew, and probably something 
like that in Phoenician, and then a B, two rooms in a 
house, beth, with examples that others would recall, Beth 
Israel, Bethlehem, Beth El. A professional linguistic 
scholar in the crowd let me down by explaining patiently 
that recent studies had clearly shown that this was much 
too simplistic an explanation, probably dead wrong. I 

ROBERT U. MASSEY, M.D., Professor, Division of Humanistic 
Studies in Medicine, Department of Community Medicine and Health 
Care, University of Connecticut School of Medicine, Farmington, CT. 

bided my time, waiting to nail him when he started to 
talk about medicine, which he was sure to do, and I did; 
between the two of us we chilled all conversation in the 
group to nothing more serious than the Red Sox. All of 
this should be a challenge, but for most of us there is just 
not enough time; first-rate scholarship is inaccessible to 
any but other specialists in the field, and if there are no 
translators, no amateurs to tell the tale, Biblia Sacra 
must remain a closed book, and those without Latin, yet 
curious about the two creation stories in Genesis, finally 
give up and switch on the ball game. 

The analogy can go too far, but the transcribers 
should themselves be amateur scholars in the discipline, 
not only masters of irregular Greek verbs; a good nov- 
elist who is not a decent historian may write a best-selling 
history, but it will be bad history, possibly dangerous. 
Scholarly findings can be written in “a language under- 
standed of the people,” even simplified, without being 
simplistic or wrong. The immune system can be success- 
fully explained to a ten-year-old without distorting a 
single fact, omitting only a tedious philosophic discus- 
sion of what a fact is. The wonder of the periodic table 
can be told in such a way as to elicit an “ah ha!” from a 
16-year-old who will never look inside a molecule or even 
a chemistry laboratory. William Harvey’s “discovery” of 
the circulation can engage the attention of a mixed 
crowd of seniors for an hour without the speaker ever 
compromising historical or biographical truth. And the 
great thing is, they will remember most of these things a 
year later, or recall them when they see or hear of them 

We may never quite bridge the chasm between the two 
cultures, much less bring serious disciplines together; 
violinists cannot understand horn players, and immu- 
nologists are no good when it comes to working out 
visual pathways, so why should we expect legal scholars 
to see the world as scientists do? But the specialists and 
scholars do need to communicate with the rest of us, or 
they need to make room for those who can. Barbara 
Tuchman was one who could manage the historians and 
all their works, and bring her strong subjectivity to 
match their cool objectivity, unafraid to write of human 
passion, folly, and goodness from her point of view, 
which she took to be ours as well. We shall miss her 
spirited telling of the tall tales of our history. 

VOLUME 53, NO. 3 


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Winter Reading: Legal Regulation of the Health Care System 


Now that the Connecticut Supreme Court has handed 
down its decision in the McConnell 1 case, it is tempting 
to leave incomplete the two-part series begun last month 
dealing with two recent health law texts. In its unanimous 
decision, the Court affirmed the right of Ms. McConnell’s 
family to implement her right to refuse artificial nutrition 
and hydration. The majority of the Court found such an 
outcome consistent with the meaning and intent of the 
Connecticut “Death with Dignity” Statute. In a concur- 
ring opinion, one justice agreed with the result, but 
articulated his own basis rooted in a common law right 
to self-determination. Since full discussion of the 
McConnell case is likely to take more than one column, I 
have decided that it would be less disruptive to proceed 
with the second part of the series this month and to take 
up the McConnell case next month. In this way, both 
topics can receive appropriate attention. 

Last month’s column and this month’s column have 
been designed to introduce two recent health law texts 
and to encourage your examination of them. This month 
the focus is on Clark C. Havighurst, who is the William 
Neal Reynolds Professor of Law at Duke University. His 
volume Health Care Law and Policy: Readings, Notes, 
and Questions 2 has been published by Foundation Press 
as part of its University Casebook Series. This is an 
impressive work of almost thirteen hundred pages which 
contains a broad range of primary and secondary sources 
in health law. Emphasizing his longstanding interest in 
regulation of the health care industry, Professor Havig- 
hurst has divided his work into four parts, addressing 

JOSEPH M. HEALEY, J.D., Associate Professor, Department of 
Community Medicine and Health Care, University of Connecticut 
School of Medicine, Farmington, CT. 

many of the most prominent issues of this aspect of 
health law: the tensions of health policy; the mechanisms 
of quality assurance; controlling health care costs, and 
cross-cutting issues involving ethics, law, and economics. 
Among the many subtopics considered in these sections 
are: the distinctive problems of regulating health care; 
entitlements and obligations with respect to health care 
access; the tension between professionalism and com- 
mercialism in health care; antitrust concerns; quality 
issues arising out of individual and institutional creden- 
tialing; liability for adverse medical outcomes; control- 
ling health care costs; and a closing section addressing 
the impact of catastrophic diseases such as AIDS on the 
health care system. In this volume, Havighurst has 
assembled a comprehensive collection of excerpts from 
medical, legal, ethical, and economic sources and has 
provided his own extremely worthwhile commentary in 
the form of notes and questions. While its length and its 
purpose as a textbook may deter the casual reader, this is 
such an extremely valuable book for those interested in 
understanding the historical foundation and contem- 
porary application of those aspects of health law involv- 
ing legal regulation of the health care process. Those who 
overcome the natural reluctance to tackle such an impos- 
ing volume will be very well rewarded. 


1. McConnell v. Beverly Enterprises-Connecticut, Inc., 209 Conn. 
692 (1989). 

2. Havighurst CC: Health Care Law and Policy: Readings, Notes, 
and Questions. Westbury, New York, The Foundation Press, Inc., 

VOLUME 53, NO. 3 




Description: Yohimbine is a 3a-15a-20B-17a-hydroxy Yohimbine-16a-car- 
boxyiic acid methyl ester. The alkaloid is found in Rubaceae and related trees. 
Also in Rauwolfia Serpentina (L) Benth. Yohimbine is an indolalkylamine 
alkaloid with chemical similarity to reserpine. It is a crystalline powder, 
odorless. Each compressed tablet contains (1/12 gr.) 5.4 mg of Yohimbine 

Action: Yohimbine blocks presynaptic alpha-2 adrenergic receptors. Its 
action on peripheral blood vessels resembles that of reserpine, though it is 
weaker and of short duration. Yohimbine’s peripheral autonomic nervous 
system effect is to increase parasympathetic (cholinergic) and decrease 
sympathetic (adrenergic) activity. It is to be noted that in male sexual 
performance, erection is linked to cholinergic activity and to alpha-2 ad- 
renergic blockade which may theoretically result in increased penile inflow, 
decreased penile outflow or both. 

Yohimbine exerts a stimulating action on the mood and may increase 
anxiety. Such actions have not been adequately studied or related to dosage 
although they appear to require high doses of the drug . Yohimbine has a mild 
anti-diuretic action, probably via stimulation of hypothalmic centers and 
release of posterior pituitary hormone. 

Reportedly, Yohimbine exerts no significant influence on cardiac stimula- 
tion and other effects mediated by B-adrenergic receptors, its effect on blood 
pressure, if any, would be to lower it; however no adequate studies are at hand 
to quantitate this effect in terms of Yohimbine dosage, 
indications: Yocon® is indicated as a sympathicolytic and mydriatric. It may 
have activity as an aphrodisiac. 

Contraindications: Renal diseases, and patient’s sensitive to the drug. In 
view of the limited and inadequate information at hand, no precise tabulation 
can be offered of additional contraindications. 

Warning: Generally, this drug is not proposed for use in females and certainly 
must not be used during pregnancy. Neither is this drug proposed for use in 
pediatric, geriatric or cardio-renal patients with gastric or duodenal ulcer 
history. Nor should it be used in conjunction with mood-modifying drugs 
such as antidepressants, or in psychiatric patients in general. 

Adverse Reactions: Yohimbine readily penetrates the (CNS) and produces a 
complex pattern of responses in lower doses than required to produce periph- 
eral a-adrenergic blockade. These include, anti-diuresis, a general picture of 
central excitation including elevation of blood pressure and heart rate, in- 
creased motor activity, irritability and tremor. Sweating, nausea and vomiting 
are common after parenteral administration of the drug. 12 Also dizziness, 
headache, skin flushing reported when used orally. 13 
Dosage and Administration: Experimental dosage reported in treatment of 
erectile impotence. 1 * 3 4 1 tablet (5.4 mg) 3 times a day, to adult males taken 
orally. Occasional side effects reported with this dosage are nausea, dizziness 
or nervousness. In the event of side effects dosage to be reduced to Vz tablet 3 
times a day, followed by gradual increases to 1 tablet 3 times a day. Reported 
therapy not more than 10 weeks. 3 
How Supplied: Oral tablets of Yocon® 1/12 gr. 5.4 mg in 


bottles of 100's NDC 53159-001-01 and 1000’s NDC 


1. A. Morales et al., New England Journal of Medi- 
cine: 1221 . November 12, 1981 . 

2. Goodman, Gilman — The Pharmacological basis i 
of Therapeutics 6th ed., p. 176-188. 

McMillan December Rev. 1/85. 

3. Weekly Urological Clinical letter, 27:2, July 4, 


4. A. Morales etal., The Journal of Urology 128: 

45-47, 1982. 

Rev. 1/85 

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MATERIAL printed in Connecticut Medicine, the Journal of the 
Connecticut State Medical Society, is covered by copyright. Written 
permission must be obtained before reproducing, in part or in whole, 
any material published in Connecticut Medicine. 

Connecticut Medicine does not hold itself responsible for statements 
made by any contributor. 

PROSPECTIVE authors preparing manuscripts for submission to 
Connecticut Medicine should consult “Information for Authors.” This 
material may be obtained from the Journal office. The manuscript, 
including references, should be typed double spaced; all material, 
including figures, should be submitted in duplicate. The transmittal 
letter should designate one author as correspondent and include his 
complete address and telephone number. 

MANUSCRIPTS should be submitted to the Editor, Robert U. 
Massey, M.D., Connecticut Medicine , 160 St. Ronan St., New Haven, 
CT. 06511. Manuscripts are received with the explicit understanding 
that they are not simultaneously under consideration by any other 

ALTHOUGH all advertising material is expected to conform to 
ethical medical standards, acceptance does not imply endorsement by 
this journal. 

REPRINTS are available at an established schedule of costs. A 
reprint rate and order form is sent to the author with his page proofs. 

SUBSCRIPTION RATE: The subscription price per year for mem- 
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membership dues. The subscription price per year for nonmembers is 
$25.00 (Canada and foreign, $40.00). Single copies $4.50. 

ADDRESS editorial and business correspondence to: 

Connecticut Medicine , 160 St. Ronan St., New Haven, CT. 06511. Tel. 
(203) 865-0587. 

CONNECTICUT MEDICINE is the official publication of the 
Connecticut Medical Society, a voluntary non-profit association or- 
ganized for scientific and educational purposes, published monthly for 
members of the Connecticut State Medical Society. I 



Letter to the Editor 

Letters to the Editor are considered for publication (subject to 
editing and abridgment), provided that they are submitted in duplicate, 
signed by all authors, typewritten in double spacing, and do not exceed 
l */ 2 pages of text (excluding references). They should not duplicate 
similar material being submitted or published elsewhere. Letters refer- 
ring to a recent Journal article should be received within six weeks of 
the article’s publication. 


To the Editor: Victims of motorcycle injuries consti- 
tute a significant portion of the trauma center’s patient 
population. The risk of death is 14 times higher than 
from an automobile accident. 

From January 1986 to June 1987, our Trauma Unit 
admitted 48 motorcycle victims; 81% were male, 65% 
were Caucasian and 85% were single. 58% of these 
patients were unemployed and 25% had a detectable 
drug on board. Ninety percent of these victims were not 
wearing a helmet. 

According to statistics printed in the Rockville, Con- 
necticut, Journal Inquirer, there were 482 people killed 
on our highways in 1988. Five percent of these deaths 
were motorcycle drivers. In our Trauma Unit, 70% of 
deaths from motor vehicle accidents occur as a result of 
head injuries; for deaths related to motorcycle accidents, 
the percentage is higher. 

In a study conducted by of the American Journal of 
Surgery, “Patterns of Injury in Helmeted and Non- 
Helmeted Motorcyclists,” accident records were reviewed 
from 1 January 1983 through 31 May 1987. There were 
367 accidents involving motorcycles. Of the injured 
motorcyclists, 64% were nonhelmeted and 36% were 
helmeted. There were 23 deaths in the nonhelmeted 
motorcyclists and seven in the helmeted. Fifty percent of 
the nonhelmeted motorcyclists sustained brain injuries 
compared to 25% of the helmeted patients. 

The injury patterns for motorcyclists versus moped 
drivers are quite similar. However, there tend to be more 
head injuries with moped drivers simply because they 
notoriously use helmets less frequently. 

The ultimate tragedy of these injuries, particularly 
head injuries, is that they effect groups whose mean age is 
from 25 to 29.9. Twenty-five percent of the impairments 
that these people suffer are irreversible. The remaining 
75% involve at least some element of reversibility, but for 
the severely brain injured, the care is often chronic, 
lasting years. The emotional impact on the victim and 
the victim’s family is extraordinarily devastating. Words 
do not sufficiently explain the enormous price which is 
paid by all involved because of one single tragic event. 

Compounding this tragedy is the cost to the public. 
The Harborview Medical Center in Seattle conducted a 
study, published in the Journal of the American Medical 
Association, in which 105 patients were evaluated in 
terms of cost. The mean time span for treatment was 20 
months, costing more than 2.7 million dollars, with an 
average of $25,764 per patient. The majority (63.4%) of 
care was paid for by public funds, with Medicaid ac- 
counting for more than half of all charges. 

In the Journal of Trauma 1986, the Massachusetts 
General Hospital published data on 47 hospitalized 
motorcyclists from 1 July 1982 to 1 July 1983. The 
average cost was $15,114 (not including rehabilitation 
costs). The authors also point out that 46% of the 
patients had no medical insurance. 

A composite of recommendations from the Journal of 
the American Medical Association and the Journal of 
Trauma is as follows: 

1. Helmet Law is recommended. 

2. In an era where social and economic accountability 
plays an increasingly important role, motorcyclists should 
provide themselves with medical and disability insurance. 

My own recommendation is that Bill 413 be enacted: 
that the law mandate helmet use and that operators of 
motorcycles be adequately insured or risk penalty by 

What is most important is life and quality of life. We 
have an obligation to protect our species by whatever 
methods necessary. We also have an obligation to avoid 
burdening the public and public funds. Society must 
begin to take responsibility for its actions and the impact 
these actions may have on other segments of the 

Anthony S. Morgan, M.D. 

Director, Trauma Services 
St. Francis Hospital and Medical Center 
Hartford, CT 


1. Rivara FP, Dicker BG, Bergman AB, Dacey R, Herman C: The 
Public Cost of Motorcycle Trauma. JAMA, July 8, 1988, vol. 260, 
no 2: 221-3. 

2. Bachulis BL, Sangster W, Gorrell GW, Long WB: Patterns of 
Injury in Helmeted and Non-Helmeted Motorcyclists. American 
Journal of Surgery , May, 1988, vol 155, 708-11. 

3. Cesare J, Morgan AS, Felice PR, Edge V: Characteristics and 
Behavior Patterns of individuals involved in Non-Fatal Traumatic 
injuries. Submitted for publication in Journal of Trauma, Febru- 
ary, 1989. 

4. Morgan AS, Chapman P, Tokarski L: Improved Care of the 
Traumatically Brain Injured. Unpublished data. 

5. Rockville CT Journal Inquirer: February 20, 1989. AP: “Traffic 
Deaths Up...” 

VOLUME 53, NO. 3 



Setting Limits: Medical Goals in an Aging Society 

By Daniel Callahan, New York, NY, Simon and Schus- 
ter, 1987. 256 pp. $18.95 

Setting Limits is a book about the rapid aging of the 
U.S. population, the potential consequences of this phe- 
nomenon for both young and old, and appropriate socie- 
tal responses. Subtitled “Medical Goals in an Aging 
Society,” Callahan’s work is public policy analysis on a 
grand scale, drawing upon historical, sociological, and 
ethical perspectives to examine the problem of aging in 
contemporary society, reciprocal obligations between 
the generations, and viable strategies for addressing the 
health care needs of the country’s growing number of 
elderly. His central conclusion, that the elderly should be 
excluded from life sustaining medical care, is likely to 
prove disturbing to the elderly, the medical community, 
and, indeed, to most Americans. 

At the heart of Callahan’s analysis are two comple- 
mentary concerns. The first is that, despite continued 
improvements in the life expectancy, health status, and 
economic well-being of the elderly (which have, in turn, 
led to expanded social roles for many older persons), old 
age has, in contemporary society, been stripped of its 
personal meaning and social significance. Callahan holds 
modern medicine largely, though not exclusively, ac- 
countable for the decline of old age as a valued and 
meaningful period in one’s life. By constantly pushing 
back the limits of a “natural life span” through the 
development of life-extending technology, medical sci- 
ence has distracted us from the ultimate ends we all face: 
physical decline, disability, and death. In old age, the 
illusion that life can be indefinitely, if artificially pro- 
longed leads the elderly to a preoccupation with “today” 
rather than to a more socially appropriate and personally 
fulfilling contemplation of their lives, their impending 
deaths, and what they will leave behind them for future 

Callahan’s second, related concern is with the escalat- 
ing economic and social costs of indefinitely prolonging 
the lives of the elderly. Again, medical science has, in the 
author’s view, played a central role in expanding these 
costs. Together with more effective public health meas- 
ures, a better standard of living, and improvements in 
personal health behavior, medical advances have virtu- 
ally ensured survival of the elderly despite the inevitable 
diseases and disabilities of old age. The result has been a 
steady increase in the number and proportion of older 
persons requiring medical care and related social serv- 
ices. Further, medical technologies under development 
are targeted largely to curing the diseases and infirmities 
of old age, thereby ensuring that the per person costs of 
caring for the elderly will be even greater in the future. In 
the case of the elderly, such costs, according to Callahan, 
know no limit. “Unlike those of younger age groups, the 
needs of the elderly for continuing good health are of 

their very nature open-ended: in old age, the conquest of 
one disease only guarantees death from some other dis- 
ease, one which, if conquered, will give way to some 
further lethal condition.” Continued attempts to address 
the open-ended health care needs of the elderly can only 
bankrupt the current system and compromise its ability 
to meet the needs of future generations. 

The author offers a two-fold strategy for addressing 
these concerns. Initially, the personal and social mean- 
ings of old age must be restructured in such a way that 
they do not depend on continued survival at any cost. 
Second, the goals of medical care for the elderly must be 
accordingly readjusted. 

In the first instance, Callahan advocates a “rediscov- 
ery” of the “life cycle” concept, characterized by rela- 
tively fixed stages, an inevitable period of decline at the 
end of life, and death as an “absolute limit.” Recognition 
and acceptance of the reality of the life cycle will, accord- 
ing to Callahan, facilitate the elderly’s understanding and 
acceptance of aging and death, and resensitize them to 
the value of both past and present. As a result, they will 
again be in a position to share with younger generations 
the special insights unique to old age. While the gifts of 
time and money that the elderly often bestow on their 
children and grandchildren may readily be done without 
or supplied by others, “ Only the aged can provide a 
perspective the young need if they are properly to envi- 
sion their own lives: that of the cycle of the generations 
and its import for the living of a life.” In Callahan’s 
words, “It should be the special role of the elderly to be 
the moral conservators of that which has been and the 
most active proponents of that which will be after they 
are no longer here.” Such a role would not only be a 
fulfilling one for the elderly, but would generate “what ... 
ought to be the primary aspiration of the old, which is to 
serve the young and the future.” 

In the second instance, medicine’s passion for expen- 
sive high technology means of prolonging life must be 
bridled and health care resources redirected to appro- 
priate care of the elderly and to ameliorating of the 
causes of premature death. In Callahan’s terms, a prema- 
ture death is one which cuts short the “natural life span.” 
That is, it is a death which occurs before, “... one’s life 
possibilities have on the whole been accomplished,” and, 
“... one’s moral obligations to those for whom one has 
had responsibility have been discharged.” While rarely 
welcomed, death~after this point in the life cycle is, he 
believes, generally seen as fitting or at least acceptable. 
For most of us, he argues, the natural life span will be 
accomplished by our late 70s or early 80s. 

For Callahan, these concepts must be more than guid- 
ing principles. In the interests of fairness, and to be 
effective in containing health care expenditures, they 
must be embodied in a uniform public policy. Under 
such a policy, the government would maintain a respon- 
sibility to assist people in living out a natural life span, 
“...but not actively to help extend life medically beyond 



that point.” By life-extending treatment, Callahan means, 
“...any medical intervention, technology, procedure, or 
medication whose ordinary effect is to forestall the 
moment of death, whether or not the treatment affects 
the underlying life-threatening disease or biological pro- 
cess.” In short, the government would be, “obliged to 
develop, employ, and pay for only the kind and degree of 
life-extending technology necessary for medicine to 
achieve and serve the end of a natural life span.” Beyond 
that point, government would, “...provide only the means 
necessary for the relief of suffering, not life-extending 

In supporting his position, Callahan’s self-assigned 
tasks are to demonstrate that the rationing of health care 
has become imperative, that to base such rationing on 
age rather than “need” is morally defensible, and that his 
proposals are pragmatically workable. To these ends, he 
provides a detailed documentation of the elderly’s con- 
tribution to mushrooming health care expenditures in 
the U.S., a painstakingly thorough analysis of our per- 
sonal and societal obligations to the elderly (and their 
obligations to society), and a set of practical guidelines 
for making individual treatment decisions under his pro- 
posed framework. 

Overall, these presentations are thoughtful and schol- 
arly. Callahan is particularly effective at anticipating, 
though rarely at refuting, criticisms of his proposals: 
that, for example, there are less worthy public expendi- 
tures that could be targeted for cost containment than 
health care for the elderly, that new ways of organizing 
and financing health care for the aged may yet be found 
to achieve what cost reductions are necessary, that deter- 
mining the end of a patient’s “natural life span” will be 
difficult if not impossible, or that the application of 
life-extending technology at any age raises the possibility 
of open-ended health care costs. Too often, Callahan 
voices but summarily dismisses such criticisms. 

In the end, however, it is the overall thrust and tone of 
the author’s analysis which is likely to trouble profes- 
sional and lay readers alike, perhaps because they run, or 
appear to run, counter to our everyday perceptions of 
reality and to our deeply held values. At the simplest 
level, it will come as a surprise to many if not most 
readers over the age of 80 to find that their remaining 
years have been stripped of meaning, whatever their 
health or social circumstances. Similarly, while Callahan 
disavows any attempt to diminish the value of the aged 
or old age, his frequent admonishment to the elderly 
that, in their “subsidized retirement,” they should “re- 
deem” old age by accepting their physical decline with 
grace and self-sacrifice in the interest of the young seems 
to suggest that today’s aged are somehow more prone 
than those of the past to self-indulgent consumerism at 
the expense of their children and grandchildren: a view 
unlikely to be held by most elderly or their families, or 
supported by scholarly research. Nor are readers likely to 

find a sense of fairness and intergenerational equity in a 
system that would deny life-sustaining treatment to an 
otherwise healthy person solely on the basis of advanced 
age, particularly when such an injunction would apply 
only to those relying on government assisted care. 

These limitations should not detract potential readers 
from their own careful examination and consideration of 
Callahan’s thesis. In Setting Limits, Daniel Callahan has 
put forth an unquestionably bold and articulate chal- 
lenge to contemporary medicine, to our health care sys- 
tem, and to the nation: do better in meeting the health 
care needs of our elderly within our existing system of 
care or prepare for widesweeping changes very much at 
odds with the traditional precepts of medicine. 

Richard A. Lusky, Ph.D. 

Director, Gerontology Studies Unit 
University of Connecticut Health Center 

Farmington, CT 


Attach your current mailing label here 
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Please give us six weeks notice. 

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Send address changes to: 

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VOLUME 53, NO. 3 


From the Executive Director’s Office 



The 1989 Annual Meeting of the House of Delegates will be held at the Ramada 
Inn, 275 Research Parkway, Meriden. The meeting will commence at 10:00 A.M. on 
Wednesday, May 10, and will continue until all business has been concluded. 
9:30 Registration and Continental Breakfast 
10:00 Call to Order 

Norman A. Zlotsky, M.D., President 

Kenneth M. Robbins, M.D., Speaker of the House 

Katherine C. Ill, M.D., Secretary 


Article V, Section 12, Par. 3 of the Bylaws of the Society provides that: 

Resolutions may be introduced by any Active, Life Member, Student Member or Postgraduate Physician Member of The Society, in compliance 

with the following provisions. 

a. All resolutions, reports and similar items of business submitted in writing and received at the office of the Executive Director not later than 
thirty days before the date scheduled for that meeting shall be considered as regular business of the House of Delegates. 

b. Component county associations or the Student Member or Postgraduate Physician Member Associations whose meetings are held later than 
thirty-five days prior to the date of the House of Delegates shall be allowed five days after the close of such meeting in which to submit resolu- 
tions, reports and similar items of business to the Executive Director’s office and still have such material considered as regular business. In no 
event, however, may such resolutions, etc:, be considered regular business if they are received later than fifteen days prior to the date of the 

c. Reports, recommendations, resolutions or other new business may be presented to the House of Delegates by the Council of The Society at 
any time and shall be considered as regular business. 

d. Any business which does not qualify as regular business in accordance with the foregoing provisions may be accepted for consideration by a 
majority vote of the delegates present and shall be referred at once by the Speaker to a reference commitee. When business is introduced under 
the provisions of this paragraph the vote shall be taken without debate, except that the introducer shall be allowed not more than two minutes 
to explain why it should be considered as regular business. 


Thursday, February 23, 1989 


Present in addition to the Chairman Dr. Joseph C. 
Czarsty were Drs. Ahamed, Beck, Bobruff, Bonner, 
Catrini, Eslami, Fox, Freedman, Hollister, Jr., Ill, Ka- 
mens, Kaufmann, McDonnell, Orphanos, Petrie, Reyelt, 
Jr., Robbins, Rubin, Sosa, Van Syckle, Villa, Welch, 
Zanker, Zeppieri and Zlotsky. 

Also present: Mr. Norbeck, Mrs. Lindquist, Mr. Bru- 
nell, Mr. Sullivan, Dr. James, Mr. Tomat (FCMA), and 
Mr. Coffey (HCMA). 

Absent were: Drs. Blum, Chmieleski, Dardick, Les- 
nik, O’Brien, Rose, Sadowski, Schwartz, Upham and 

Physicians Serving on State and Federal Agencies 

Dr. Kamens, Medical Director of CPRO, reported 
that CPRO has had its contract renewed effective April 
1, 1989 and it is called the “third scope of work.” There 
have been some significant changes which again include 
precertification of some procedures. The federal govern- 

ment has devised a specific methodology for quality of 
care issues and assigned points to these issues. The 
CPRO will keep hospitals informed of the various changes 
being undertaken. 

Dr. Kamens also discussed a report that had appeared 
in the New York Times concerning deaths occurring due 
to drug reaction among the elderly, reportedly caused by 
misdiagnosis, lack of emphasis on geriatric training, 
faulty prescription writing and patient misuse. He sug- 
gested that perhaps CSMS would wish to make a pilot 
study of these allegations. Following discussion, it was 
VOTED that the Chairman of the Council appoint a 
small committee of councilors and staff, along with Dr. 
Kamens, to investigate the potential to implement a 
program of study such as outlined and report back to the 

Report to the President 

Dr. Zlotsky reported on the following items: 

Legislation — He appeared at a hearing on the use and 
abuse of steroids in athletes and an attempt will be made 
to make steroids a controlled substance. Dr. David 
Thompson of New London presented excellent testi- 



mony at a hearing on triplicate prescription; however, 
the outcome on this legislation is unpredictable. Medi- 
care Assignment has been killed in two committees and 
the only way it can resurface is as an amendment to 
another bill, and this will have to be monitored carefully. 
The Nurse Prescription Bill, which was written by an 
attorney from the Health Department was reviewed by 
Drs. Zlotsky and Beck and several changes were made in 
the bill, although some items remain in the bill which are 
not entirely satisfactory. Dr. Zlotsky called on Dr. Zanker 
to discuss the issue of budget cuts in the funding of 
nursing homes by the Department of Income Mainte- 
nance. The issue will be studied by the CSMS Legislative 

Legislative Fitness Day — A legislative fitness day is 
being co-sponsored with the Governor’s Fitness Com- 
mittee on March 15th at the state capitol. Members of 
the CSMS Committee on Sportsmed will be on hand to 
take the various tests and brochures will also be availa- 
ble. Any expense for this program is being underwritten 

Tort Reform — Attorney Donald Elliot, who researched 
the constitutionality of establishing a cap on non-eco- 
nomic damages, is currently preparing model legislation 
which it is felt would have the best chance of being held 
constitutional in Connecticut. 

CM MI — At the present time, the bylaws committee did 
not meet to discuss the possibility of providing for spe- 
cific members to be seated on the CMIC Board. Dr. 
Eslami assured the Council that this issue would be 
discussed when the bylaw committee meets, and that the 
interest of CSMS in CMIC would be protected. 

Report of the Executive Director 
Tim Norbeck reported on the following items: 
Malpractice Insurance — A letter was distributed to the 
Council members from the St. Paul Insurance Company 
responding to the release by the Minnesota Commerce 
Department on their “Malpractice Claim Study, 1982- 
87” and subsequent nationwide “Nightline” program 
which asserted that inflated loss reserves were driving 
unnecessary premium increases. St. Paul engaged their 
own actuarial firm to review the report and the findings 
were that the report used unsound procedures and inap- 
propriate data in evaluating reserve adequacy and rate 
levels and the conclusions were incorrect. 

AM A Nominations — Dr. Petrie is campaign manager 
for Dr. Kamens who is running for a slot on the Council 
on Medical Service and Dr. Freedman is campaign 
manager for Dr. Yapp, who is seeking the resident slot 
on the AMA Board of Trustees. Promotional material 
has been developed for both campaigns and will be 
mailed to members of the AMA House of Delegates. 

Ad Hoc Committee on Membership 
Dr. Freedman reported that the committee is making 
an ongoing effort to increase CSMS membership and 
requested that counties and individual physicians assist 

in this program by enlisting new members. He reported 
that two large counties have large numbers of physicians 
who belong to the county only and not the state. Every 
effort will be made to have these two counties discon- 
tinue the practice of county members only and it was 
suggested that if this trend could not be stopped, that 
CSMS should consider allowing State Society members 
only in those counties that allow county membership 

Update M.D. Health Plan 

Dr. Van Syckle reported on the progress being made 
between the recent stock offering and the new physician 
enrollment program. Approximately 250 additional physi- 
cians have joined the program bringing the total up to 
2,000 physician participants. An appropriate network of 
physicians is being developed and with additional focused 
recruitment, the needs of the program will be met in the 
near future. At the present time there are over 12,000 
members and the plan continues to grow. January was 
its first million dollar month. 

Charitable Trust 

Melinda Agsten, Attorney from Wiggin & Dana, 
joined the Council to review the actions to be taken to 
implement the Charitable Trust. The Council had pre- 
viously approved the establishment of a Charitable Trust 
in March of 1988. Copies of the Trust Agreement were 
distributed with the agenda to all members of the Coun- 
cil. Following detailed discussion, it was VOTED to 
approve the documents submitted with the following 

a. Change references to “President of the Council” to 
“President of the Society.” 

b. That the President of CSMS select the Trustees and 
submit to the Council for approval. 

c. That under the provision for removal of trustees, it 
be noted that advance notice be given by two-thirds 
of the trustees present and voting and that removal 
be with or without cause. 

d. Successors — When vacancy occurs for any reason, 
notice should be given immediately to the Council to 
name a successor. 

e. Terms should be limited to two terms of three years 
each and should be staggered. 

f. No compensation for trustees. 

f. Trustees cannot amend Trust without CSMS Coun- 
cil approval. 

Connecticut Physician’s Group Purchasing Plan, Inc. 

At the House of Delegates on May 4, 1988, a resolu- 
tion was approved “That the rights and powers of CSMS 
as a shareholder of Connecticut Physicians Group Pur- 
chasing Plan, Inc. shall be exercised by the Council of 
CSMS, and the Council is hereby authorized and em- 
powered to act on behalf of CSMS with respect to all 
matters concerning CPGPP.” It was VOTED to approve 
the Bylaws with the suggestions that an appropriate 

VOLUME 53, NO. 3 


name be given to the corporation. It was further VOTED 
to approve the resolution authorizing the President and / 
or Executive Director to take whatever actions necessary 
to establish the subsidiary in compliance with the Bylaws. 

Public Information Program 

Dr. Sosa had suggested that the Auxiliary study the 
feasibility of having store fronts on Main Streets in each 
county to serve as public information stations. Dr. Czar- 
sty reported that Mrs. Reed, Auxiliary President, had 
informed him that the Auxiliary did not have the man- 
power to undertake such a proposal. Following discus- 
sion, it was suggested that county medical associations 
be encouraged to establish programs of public informa- 
tion on health related matters and also encourage careers 
in health, with the assistance of the Executive Director’s 
office in planning programs. It was VOTED to refer this 
suggestion to the Committee on Public Affairs for study 
and implementation. 

Ray Sullivan reported on the items that the Committee 
on Public Affairs is currently undertaking, i.e., TV pro- 
grams, participation in the Health Fair, where choles- 
terol screening will be done, pamphlets on economic and 
health related issues, press releases on current medical 
subjects and arranging interviews on radio talk shows. 

Report of Subcommittee on Preliminary 
Study of Nominations 

With a few amendments, it was VOTED to approve 
the report of the Subcommittee and to transmit the 
complete slate of nominees to the House of Delegates for 
election with Council recommendation for approval. It 
was further VOTED to increase the Committee on Phy- 
sician Health to 15 members and to rename the Commit- 
tee on Allied Medical Services to the Joint Practice 
Committee with the Connecticut Nurses Association. It 
was also VOTED that Dr. Zlotsky would chair a new 
Committee on Allied Medical Services and submit a list 
of nominees for the committee to the Council at the next 
meeting. The charges to the committees would be re- 
structured accordingly. 

Committee on Statewide Medical Planning 

Several items were referred to the committee for study 
and following is the action taken on the various reports: 

a. Section on Employed Physicians — At the September 
1988 Council meeting, it was voted to refer the 
concept of a Section on Employed Physicians to the 
Committee on Statewide Medical Planning for study. 
It was VOTED to approve the recommendation of 
the committee that a poll be undertaken of employed 
physicians to seek out their interests and that $2,000 
by allotted for this purpose. Dr. W. Raymond 
James, Chairman, who joined the Council to discuss 
the issue, stated that after studying the findings of 
the poll, the committee would make further recom- 
mendations to the Council. 

b. Third Party Payors — At the September 1988 Coun- 
cil meeting, the Committee on Statewide Medical 


Planning was also charged to investigate feasible 
methods of preventing third party payors’ intrusion 
into medical care. The committee reported that this 
issue has been of major concern for many years. The 
patients, or their employers, have long ago signed 
over their rights to privacy and to compensation 
without third-party interference and physician com- 
pensation has been a casualty. Affected parties should 
send letters of complaint to third party payors with 
copies to insurance company presidents, insurance 
commissioner, patient employer and appropriate 
attorneys. It was VOTED to accept the report as 

c. Universal Health Planning — At the January 1989 
Council meeting a communication from Congress- 
man Bruce Morrison’s Medical Advisory Commit- 
tee seeking a proposal from CSMS for the structure 
of universal healthcare insurance in Connecticut 
was referred to the committee for study. Dr. James 
reported that CSMS and AMA had recently com- 
pleted participation in the formulation of the “Health 
Policy Agenda for the American People” involving 
over 425 representatives from 172 different health, 
health-related, business, government, and consumer 
groups who met over five years to confront the 
issues confronting the health sector into the next 
decade and the outcome of this broad consensus was 
published last year. Following discussion, it was 
VOTED that the Council forward the HPA recom- 
mendations 135 to 147, “Designing a Cost-Effective 
Payment System” and recommendations 148 to 161, 
“Defining the Role of the Government” to Mr. Fre- 
berg and the members of the Medical Advisory 
Committee, with an offer to refer them to physician 
experts in medical economics in Connecticut. 

Committee on Insurance 

At the Council’s request, the Committee on Insurance 
conferred with disability insurance carriers to determine 
their attitudes toward payments to physicians who are 
HIV positive but do not have AIDS and who are not 
allowed to practice in a hospital because of possible 
contamination of patients. The committee met with 
representatives of the CSMS disability insurance cover- 
age and received the following information from the two 
companies involved: 

a. AIDS would be considered a covered disability once 
the symptoms actually became physically disabling. 

b. No insurance carrier would commit right now to a 
ruling regarding a hypothetical situation, like the 
one suggested by the committee, until a test case is 
actually physically disabled, then she/he would be 
covered by the insurance. However, to be deemed 
totally disabled for the purpose of collecting disabil- 
ity insurance because of testing positive for HIV 
infection, but before any symptoms are manifested, 
is not likely, unless there is a court ruling that sets a 
legal precedent. 


Resolution on Restraints Placed on Physicians by Claims 
Made Professional Liability Carriers 

At the last Council meeting, the subject resolution, 
which was referred to the Council by the House of 
Delegates was referred to CM MI for study. The resolu- 
tion was as follows: 

“Resolved, That the CSMS Council investigate the 
possibility of having a reciprocal agreement among pro- 
fessional liability companies so that a physician may 
contemplate establishment of a medical practice in an- 
other state without the purchase of tail coverage, thus 
allowing the physician more mobility from one state to 
another. A reply has been received from CMIC indicat- 
ing that this issue is one of national concern and being 
studied by the Physician Insurance Association of Amer- 

ica and the AM A. The results of a study will be presented 
at a workshop in Boston on May 18-20, 1989 and a more 
definite response to the problem may be available at that 
time. It was VOTED to receive the communication as 

Life Members 

It was VOTED to receive the following list of Life 
Members as information: 

William E. Hill, M.D., Naugatuck (NH) 

David Luchs, M.D., Colebrook (L) 

N.B.: The foregoing is a summary of the proceedings 
and actions of the Council on February 23, 1989. 
Detailed minutes of the meetings are on file at 160 
St. Ronan Street, New Haven, for perusal by any 
interested member of the Society. 



M.D. Health Plan reached a significant plateau in January with monthly premium billings exceeding $1,000,000. 
Enrollment has also been brisk. For the first quarter of 1989 (January, February, March), M.D. Health Plan’s 
enrollment grew 65%, serving over 13,800 HMO members in 127 major employer groups. This represents 11,000 
more members than at this time last year. Projected enrollment for the first quarter of 1989 was 12,000. As of March 
21, M.D. Health Plan is 15% ahead of projection. 

Additionally, in July, 1988, the Company diversified into innovative new products and services. The employer 
self-funded cost containment program MedCHOICE Health Care Network (MedCHOICE) has generated 5,000 
new enrollees since July. The combined enrollment for M.D. Health Plan and MedCHOICE now exceeds 18,800 

M.D. Health Plan made a $53,000 profit in January and $54,000 profit in February. The profit was a result of 
favorable medical cost experience and less than expected administrative cost. March’s profit is expected to be higher 
as medical costs continue to trend lower than projection. 

At this pace, M.D. Health Plan and MedCHOICE will generate $12,000,000 in physician fees and 100,000 
patients’ visits to participating CSMS-IPA physicians in 1989. 

By all industry standards, M.D. Health Plan and MedCHOICE are a success. Other Connecticut HMO’s which 
began operations at roughly the same time, have less than half the number of enrollees. 

VOLUME 53, NO. 3 



The Society maintains the Physician Placement Service as a service to the medical profession in Connecticut. 
Opportunities for physicians to locate in Connecticut will be published as space permits and will be distributed 
to physicians making inquiries of such opportunities. Information should be sent to 160 St. Ronan St., New 
Haven, CT 06511 (203-865-0587). 

Physicians wishing to establish practice in Connecticut are invited to submit a resume to be kept on file with 
the Society. An announcement of a physician’s availability will be published in two issues of Connecticut 
Medicine as space permits. 

Listing of physicians in the Placement Service does not in any way represent certification by the Society. 
Investigation of credentials and experience is the responsibility of those seeking applicants for positions. 



Colchester — BC/BE Family Physician wanted to join busy solo Fam- 
ily Practice. Guaranteed income; good benefits; good coverage and no 
obstetrics. Potential for partnership in two years. Please send CV to: 
Dr. Kassem M. Khybery, 79 Norwich Ave., Colchester, CT 06415. 


BC/BE Internist to join three MD Internal Medicine Group in the New 
Haven area. Send CV to CSMS, c/o IM/NO. 

Internist wanted as full-time Staff Physician for 568 bed multi-licensed, 
JCAH accredited geriatric institution and continuing care retirement 
community in Central Connecticut. Geriatric experience preferred. 
Will work standard workweek; rotation of evening and weekend call. 
Please send curriculum vitae with salary requirement to: CSMS, 

Internist wanted to join existing division of three faculty geriatricians in 
academic setting to provide patient care for home care, nursing home, 
inpatient and outpatient evaluation programs, starting July 1989. 
Ongoing academic involvement including opportunities for teaching 
and/or research available, if desired. Competitive salary and benefits, 
no night or weekend call and four weeks vacation. For information 
contact: Fitzhugh C. Pannill, III, M.D., Chief, Division of Geriatrics, 
West Haven VA Medical Center, West Spring St., West Haven, CT 


Retired physician’s fully-equipped office, including X-ray, available for 
immediate rental or sale. Excellent location. Please reply: Judith 
Turetsky, 496 West McKinley Ave., Bridgeport, CT 06604. (203) 367- 
9300 for further information. 

Plant Physician. The Pfizer Inc. Chemical Production facility in 
Groton has an immediate need for a Physician to manage the Plant 
Medical Department which consists of seven employees. Duties include: 
Providing industrial health services to a facility of 1,800 employees; 
providing treatment and referral for emergencies and occupational 
illnesses and injuries; developing innovative medical programs to 
address employee health and safety issues; providing support in disabil- 
ity return-to-work program, EAP, and case management. The success- 
ful candidate will have an MD degree and license to practice medicine; 
strong management and interpersonal skills; experience in an industrial 
or military setting a plus. We offer an excellent compensation and 
benefits package. Please send your resume in confidence with salary 
requirements to: Mr. Barton S. Finegan, Director of Employee and 
Community Relations, Pfizer, Inc., Eastern Point Rd., Groton, CT 
06340. EOE. 

Fee-basis, part-time, physicians needed to assist in physical examina- 
tions at the New Haven Military Entrance Processing Station. Ideal for 
retired family practitioners, internists and pediatricians. MD’s or DO’s 
must be licensed in a state or territory of the United States, DC or PR. 
No malpractice insurance needed. $125.00 to $150.00 for short morn- 
ing. Call Dr. Gerhard Mack (203) 787-3823 or write: Commander, New 
Haven MEPS, 150 Court St., 4th floor. New Haven, CT 06510-2056. 


Recently trained, solo, OB/GYN, Board Certified seeks BE/BC asso- 
ciate for busy private practice in a beautiful resort community in 
southern Connecticut. Excellent opportunities for higher education, 
water recreation, and shopping. Easy access to New York City, Boston, 
Hartford and Cape Cod. Very stable economy with low unemployment. 
Would consider two physicians relocating together. Please forward CV 
to: Stanley P. Solinsky, M.D., 350 Montauk Ave., New London, CT 


Orthopedic surgeon. Hartford, CT area. Part-time, board certified/el- 
igible with clinical interest in Adult Orthopedics. Responsibilities 
include Inpatient Consultation/ Referral and Outpatient Clinic Activi- 
ties. Flexible hours; licensure in any state accepted; malpractice insur- 
ance provided. Salary commensurate with education/experience. 
E.O.E. Please respond with CV to: Shutish Patel, M.D., Acting Chief 
of Staff, V.A. Medical Center, 555 Willard Ave., Newington, CT 


Full-time or permanent part-time position with growing practice in 
eastern Connecticut. Position available now and includes coverage in 
two hospitals and two private imaging offices. Competitive salary and 
fringe benefits. Shoreline area is a great place to live. Send CV to: John 
Foster, M.D., 21 Montauk Ave., New London, CT 06320. 



July ’89. Age 36. Presently in practice. FLEX. AB cert. MD, Int. and 
Res., Louisiana State University, Shreveport, LA. Prefers group, asso- 
ciate or institutional type practice in a medium-sized community pref- 
erably the New Haven area. Write, Ann W. Younker, M.D., 171 
Ockley Dr., Shreveport, LA 71 105. 




July ’89. Age 34. Nat’l bds. AB elig. MD, College of Physicians & 
Surgeons of Columbia University, New York, NY; Int. and Res., Mt. 
Sinai Medical Center, New York, NY. Prefers group or associate type 
practice in a large-sized community. Write, CSMS, c/o RA/GS. 


July ’89. Age 30. Nat’l bds. MD, Tufts University School of Medicine, 
Boston, MA; Int. and Res., St. Elizabeth’s Hospital, Boston, MA. 
Prefers group practice with or without vascular surgery, teaching or 
private practice. Write, John T. Frasca, M.D., 130 Nichols St., Nor- 
wood, MA 02062. 


Presently available. Age 61. Licensed in Connecticut. Nat’l bds. AB 
cert., (SURG). MD, Columbia University, New York, NY; Int. and 
Res., Hartford Hospital. Interested in institutional position involving 
primary care and/or utilization management. Prefers central Connec- 
ticut area. Occupational physician for 12 years with a major corpora- 
tion. Write, Peyton H. Mead, M.D., 2 Mead Lane, Balbrae, Bloom- 
field, CT 06002. 


May ’89. Age 29. Presently in practice. FLEX. AB elig. MD, Boston 
University, Boston, MA; Int. and Res., Santa Clara Valley Medical 
Center, San Jose, CA. Prefers group type practice in a small-sized 
community. Write, Mark D. Doner, M.D., 101 Lindero St., Lindsay, 
CA 93247. 

Cardiology. Dec. ’89. Age 32. Flex. AB cert. MD, Government Medi- 
cal College, Surat, India; Int., Detroit Macomb Hospital Corp., 
Detroit, MI: Res. and Fellowship, St. Joseph Mercy Hospital, Pontiac, 
MI; Prefers solo or associate type practice in a small to medium-sized 
community. Write, Mukeshchandra M. Patel, M.D., 900 East Blvd. 
South, Apt. F-124, Pontiac, MI 48053. 

Gastroenterology. July ’89. Age 28. Nat’l bds. AB elig. MD, Mount 
Sinai School of Medicine, NY, NY: Int. and Res., Long Island Jewish 
Medical Center, New Hyde Park, NY; Fellowship, Booth Memorial 
Medical Center, Flushing, NY. Prefers solo, group or associate type 
practice. Write, Jeffrey T. Dreznick, M.D., 63-53 Haring St., Apt. 608, 
Rego Park, NY 1 1374. 

Rheumatology. July ’90. Age 29. Nat’l bds. AB cert. MD, University of 
South Florida, Tampa, FL; Int., Medical College of Georgia, Augusta, 
GA; Res. and Fellowship, University of South Florida. Group or 
associate practice most desirable. Currently in first two years of Rheu- 
matology fellowship at USF affiliated hospitals, Tampa. Write, John 
P. Gresh, M.D., 6342 Bentbranch Court, Tampa, FL 33617. 


Physician in practice for 30 years seeking part-time employment possi- 
bly leading to full-time employment in reviewing charts, hospital 
records and claims. Write, CSMS, c/o HM/PT. 


$60.00 for 25 words or less; $1.00 for each 
additional word. 

$3.00 per insertion for confidential 
answers sent in care of CONNECTICUT 
MEDICINE. Payable in advance. 

OB/GYN — WATERBURY, CT — Enjoy the opportunity to really 
practice medicine without worrying about insurance, billing and staff- 
ing problems. CTs first staff model HMO offers a highly competitive 
compensation package with regularly scheduled hours. Send CV with 
salary requirements in confidence to: Mr. Daniel Lenhart, Personnel, 
CHCP, 221 Whitney Ave., New Haven, CT 06511. EOE M/F. 

rent. Prime location. Stamford. A package deal or any other arrange- 
ment can be made. Call: (203) 323-6655, (203) 322-5118. 

BOCA RATON, FLORI DA’S finest lakefront plus one acre plus 8000 
sq. ft. luxury home. Call Madsen/ Klecz for information and brochure. 
(1) 800-222-8155. J. B. Dolan Realty. 

strong interpersonal and communications skills and extensive back- 
ground in administrative management is seeking a responsible man- 
agement position with medium to large medical group. Experienced in 
group insurance and investment product administration. Contact Wil- 
liam Edgerly (203) 726-7105 or 621-6144 (evenings). 

ROCKINGHAM, VERMONT — Charming c.1819 Center-Chimney 
Cape on quiet dead-end road with views of Connecticut River Valley. 
Rumford fireplace; original antique paneling; wide board floors; lovely 
windows. Great bird-watching area, close to boat ramp and easy access 
to 1-91. $159,700. Call REALTY WORLD/ Homestead Realty. (802) 

DOCTORS OFFICE in medical building condominium. Reception, 
waiting area, three exam rooms, x-ray and developing and lav. In 
move-in condition for sale or lease. Other office available. Call Bar- 
berino-Ennis Property Management (203) 269-9092. 

VOLUME 53, NO. 3 


Around the State 

A course titled “A Real Return on Your Investment: The 
Educated Patient,” will be held on 29 June 1989 at the 
University of Connecticut Health Center. The theme will be 
patient education and the role of physicians, nurses, phar- 
macists, and others in the health care team in making 
patients aware of cardiovascular risk factors. For more 
information, call Cecile J. Volpi, 679-3340. 

Israeli- American Neonatology Symposium Set for June 
’89. The first Israeli-American Neonatology symposium 
will take place in Jerusalem from 29 June to 9 July 1989 
under the co-sponsorship of Norwalk Hospital’s Depart- 
ment of Pediatrics. Coordinator of the undertaking is Peter 
S. Czuczka, M.D., of Westport. 

The symposium will provide an opportunity for the 
exchange of ideas on neonatal topics between prominent 
physicians of both countries. Ian Gross, M.D., chief of 
neonatology, and Joseph Warshaw, M.D., chairman, de- 
partment of pediatrics, both of the Yale Medical School, 
will be lecturers. 

The Second Annual Conference on Lyme disease will be 
held on Wednesday, 7 June 1989 at Yale Medical School. 
This year’s topics include: 

• The ecology of Lyme disease including protective 

• Lyme disease in veterinary medicine. 

• Animal models of Lyme disease and what they teach 
us about the disease in humans. 

• The management of tick bites and treatment of Lyme 
disease in pregnancy. 

• Work in progress regarding vaccine development. 

• Controversies regarding optimal antibiotic therapy 
for all stages of Lyme disease. 

• Late neurologic sequelae of Borrelia burgdorferi infec- 

Roche Laboratories will help to support this program. 

George B. Longstreth, M.D., a Fairfield general surgeon, 
produced the Health ’88 Seminar for the Fairfield Chamber 
of Commerce. The seminar included workshops featuring 
Jay L. Meizlish, M.D., a Fairfield cardiologist, and Edward 
M. Staub, M.D., a Fairfield orthopedic surgeon. Dr. Long- 
streth serves as the Vice President of the Chamber’s Profes- 
sional Division. 



4:00 P.M. 

Business Meeting 

4:30 P.M. 

Panel Discussing 

“Prescriptive Authority for Nurses' 

5:30 P.M. 

Cocktail Hour 

6:30 P.M. 

Dinner (Guest Speaker) 





There are no known contraindications to the use of sucralfate. 


Duodenal ulcer is a chronic, recurrent disease. While short-term treatment 
with sucralfate can result in complete healing of the ulcer, a successful course 
of treatment with sucralfate should not be expected to alter the post-healing 
frequency or severity of duodenal ulceration. 

Drug Interactions: Animal studies have shown that simultaneous admin- 
istration of CARAFATE (sucralfate) with tetracycline, phenytoin, digoxin, or 
cimetidine will result in a statistically significant reduction in the bioavailability 
of these agents. The bioavailability of these agents may be restored simply by 
separating the administration of these agents from that of CARAFATE by two 
hours. This interaction appears to be nonsystemic in origin, presumably result- 
ing from these agents being bound by CARAFATE in the gastrointestinal tract 
The clinical significance of these animal studies is yet to be defined. However, 
because of the potential of CARAFATE to alter the absorption of some drugs 
from the gastrointestinal tract the separate administration of CARAFATE from 
that of other agents should be considered when alterations in bioavailability 
are felt to be critical for concomitantly administered drugs. 

Carcinogenesis, Mutagenesis, Impairment of Fertility: Chronic oral 
toxicity studies of 24 months' duration were conducted in mice and rats at 
doses up to 1 gm/kg (12 times the human dose). There was no evidence of 
drug-related tumorigenicity. A reproduction study in rats at doses up to 38 
times the human dose did not reveal any indication of fertility impairment 
Mutagenicity studies were not conducted. 

Pregnancy: Teratogenic effects. Pregnancy Category B. Teratogenicity 
studies have been performed in mice, rats, and rabbits at doses up to 50 times 
the human dose and have revealed no evidence of harm to the fetus due to 
sucralfate. There are, however, no adequate and well-controlled studies in 
pregnant women. Because animal reproduction studies are not always pre- 
dictive of human response, this drug should be used during pregnancy only if 
clearly needed. 

Nursing Mothers: It is not known whether this drug is excreted in 
human milk. Because many drugs are excreted in human milk, caution should 
be exercised when sucralfate is administered to a nursing woman. 

Pediatric Use: Safety and effectiveness in children have not been 


Adverse reactions to sucralfate in clinical trials were minor and only rarely led 
to discontinuation of the drug. In studies involving over 2,500 patients treated 
with sucralfate, adverse effects were reported in 121 (4.7%). 

Constipation was the most frequent complaint (2.2%). Other adverse effects, 
reported in no more than one of every 350 patients, were diarrhea, nausea, 
gastric discomfort, indigestion, dry mouth, rash, pruritus, back pain, dizziness, 
sleepiness, and vertigo. 


There is no experience in humans with overdosage. Acute oral toxicity studies 
in animals, however; using doses up to 1 2 gm/kg body weight could not find a 
lethal dose. Risks associated with overdosage should, therefore, be minimal. 


The recommended adult oral dosage for duodenal ulcer is 1 gm four times a 
day on an empty stomach. 

Antacids may be prescribed as needed for relief of pain but should not be 
taken within one-half hour before or after sucralfate. 

While healing with sucralfate may occur during the first week or two, 
treatment should be continued for 4 to 8 weeks unless healing has been 
demonstrated by x-ray or endoscopic examination. 


CARAFATE (sucralfate) 1-gm tablets are supplied in bottles of 100 (NDC 
0088-1712-47) and in Unit Dose Identification Paks of 100 (NDC 0088- 1 71 2-49). 
Light pink scored oblong tablets are embossed with CARAFATE on one side 
and 1712 bracketed by C's on the other. Issued 1/87 


1 . Eliakim R, Ophir M, Rachmilewitz D: J Clin Gastroenterol 1987;9(4):395-399. 


Another patient benefit product from 







Meckel’s Diverticulum in the Pediatric Surgical Population 


Abstract— Meckel’s diverticulum is the most common 
congenital anomaly of the gastrointestinal tract. We 
reviewed our experience with 31 cases of Meckel’s diver- 
ticulum in children from 1966 to 1987. Twenty-four 
patients presented with clinical manifestations: ten from 
bleeding, ten from obstruction, and four from diver- 
ticulitis. Seven Meckel’s were incidental findings at lapa- 
rotomy. Fifty percent of the patients with bleeding had 
abdominal pain and 100% had ectopic gastric mucosa in 
the Meckel’s. In six cases the technetium scan identified 
the Meckel’s; there was one false negative scan. Ob- 
struction secondary to a Meckel’s diverticulum was due 
to an internal hernia in five and to intussusception in five. 
Three patients with intussusception had concomitant 
bleeding. Diverticulitis was clinically similar to appen- 
dicitis. There were no complications and no deaths fol- 
lowing surgical resection of Meckel’s diverticulum. 


M ECKEL’S diverticulum is the most common con- 
genital anomaly of the gastrointestinal tract, 1 
occurring in about 2% of the population. 2 Meckel’s 
diverticula most often present as incidental findings at 
autopsy or laparotomy but 8-22% of Meckel’s will pres- 
ent with symptoms from the diverticulum. 1 

In an effort to clarify the clinical presentation of symp- 
tomatic Meckel’s and the pathologic correlates with clin- 
ical disease, we reviewed our experience with 3 1 cases of 
Meckel’s diverticula. 


From 1966-1987, 3 1 children had resection of a Meck- 
el’s diverticulum. Seven Meckel’s were removed inci- 
dentally during other operations and 24 were removed 
for symptoms. The ages ranged from newborn to 17 
years, with an average age of four years; there were 18 
males and 13 females. 

Ten patients presented with gastrointestinal bleeding, 
ten with obstruction, and four with diverticulitis. Bleed- 
ing was described as melanotic stool in six patients and 

COLLEEN BROPHY, M.D., Postdoctoral Fellow, Department of 
Surgery. JOHN SEASHORE, M.D., Professor, Section of Pediatric 
Surgery; both of the Yale University School of Medicine, New Haven, 

bright red blood in four patients. Five of the ten patients 
had abdominal pain in addition to the bleeding. The pain 
was usually characterized as crampy; it was acute in four 
patients and had been present intermittently for four 
months in one patient. Seven patients had a 99mTc- 
pertechnetate scan which was positive in six (Fig. 1). In 
six patients the bleeding was severe enough to require 
transfusion. All patients with bleeding from a Meckel’s 
diverticulum had ectopic mucosa and five of ten had an 
ulcer in the adjacent ileal mucosa. 

Obstruction was due to a band in five patients and to 
intussusception in five. Patients less than one year old 
presented with vomiting and lethargy, and those over 
one with vomiting and abdominal pain. Three patients 
with obstruction due to intussusception had prior ep- 
isodes of rectal bleeding and crampy abdominal pain 
suggesting intermittent intussusception. 

Meckel’s diverticulitis was clinically similar to appen- 
dicitis; perforation occurred in three of the four patients. 

Simple diverticulectomy was performed in 26 patients. 
Five patients had a segmental resection. Appendectomy 
was performed in 18 of 24 cases. There were no compli- 
cations or deaths in this series. 

Seven patients had an incidental diverticulectomy, 
three associated with an appendectomy, two omphalo- 
cele repair, one choledochal cyst, and one duodenal 
atresia. Meckel’s diverticula that were discovered inci- 
dentally but not removed are not included in this study. 


The first recorded observation of an ileal diverticulum 
was by Fabricus Hildamus in 1650. 4 In 1745 Littre de- 
scribed the presence of a diverticulum in a hernia. 5 It was 
not until 1809 that Johann Friedrich Meckel recognized 
the association of the diverticulum with the omphalomes- 
enteric duct and, in doing so, accurately delineated the 
anatomy and embryology of the structure that bears his 
name. 6 Subsequent observations include the description 
of a small bowel obstruction secondary to a Meckel’s 
diverticulum by Kuttner in 1 898, 7 the presence of ectopic 
gastric mucosa in a diverticulum by Salzer in 1904, 8 and 
Meckel’s diverticulitis mimicking appendicitis by Gra- 
men in 19 1 5. 9 

VOLUME 53, NO. 4 


Meckel’s diverticulum results from failure of complete 
obliteration of the vitelline (omphalomesenteric) duct. 
The vitelline duct joins the yolk sac with the gut and is 


Figure 1 

99mTc-pertechnetate scan. The arrow points to the Meckel’s diverticu- 
lum in the positive scan. 

usually obliterated during the fifth to the seventh week of 
gestation when the placenta replaces the yolk sac as the 
source of nourishment for the fetus. Persistence of all or 
part of the duct can result in numerous anomalies, 
including a fistula, an enterocystoma, a fibrous band, or, 
most commonly, a Meckel’s diverticulum 7 0 ’ ! 1 The blood 
supply of a Meckel’s diverticulum is derived from the 
paired vitelline arteries; normally the left artery involutes 
and the right forms the superior mesenteric artery. Vesti- 
gial remnants of the vitelline arteries may connect with the 
abdominal wall or to the small intestine mesentery form- 
ing a band around which a volvulus or internal hernia 
may develop. 

Pathologically, a Meckel’s diverticulum is a true diver- 

Figure 2 

Obstruction secondary to a Meckel’s diverticulum. On the left is an 
intraoperative photograph of an intussusception secondary to a Meck- 
el’s. After reduction of the intussusception a large Meckel’s diverticu- 
lum is seen on the right photograph. 

ticulum containing all layers of the intestine. It arises on 
the antimesenteric border of the ileum, usually within 
90cm of the ileocecal valve. Thirty to fifty percent of 
Meckel’s diverticula contain ectopic gastric, pancreatic, 
colonic, duodenal, or endometrial tissue. 12 In this series 
58% of symptomatic Meckel’s contained ectopic mucosa, 
whereas none of the incidentally removed diverticula 
contained ectopic mucosa. 

99mTc-pertechnetate scans have been used to identify 
a Meckel’s diverticulum preoperatively. 14 ’ 15 The specific- 
ity of 99mTc-pertechnetate scanning is 95%, and the 
sensitivity 85%, for a diagnostic accuracy of 90%. 16 False 
positive scans may arise if enteric duplications contain- 
ing ectopic mucosa are present. False negative scans arise 
if there is an absence of gastric mucosa, hypermotility 
secondary to brisk bleeding with a washout effect, or if 
overlapping images (bladder or stomach) obscure the 
Meckel’s. In this series six scans were positive and there 
was one false negative scan (Fig 1). 

Eight to twenty-two percent of Meckel’s present with 
symptoms; the remaining are discovered incidentally at 
laparotomy or at autopsy. 1 In this series 24 cases of 
Meckel’s diverticulum resulted in clinical manifestations, 
and seven were incidental findings at laparotomy. Bleed- 
ing and obstruction were the most common clinical pre- 
sentations, with diverticulitis more rarely encountered in 
the pediatric group. Although bleeding secondary to a 
Meckel’s diverticulum is usually described as painless, 13 
half of the patients with bleeding Meckel’s in this series 
had concomitant abdominal pain. All of the patients 
with bleeding had ectopic gastric mucosa, and 50% had 
an ileal ulcer. Bleeding from a Meckel’s is usually self- 
limited, but 70% of patients in this series with bleeding 
required a transfusion. 

Meckel’s diverticula may cause intestinal obstruction 
from intussusception, volvulus around a vitelloumbilical 
band, an internal hernia through a mesodiverticular 
band, incarceration in a hernia (Littre), or adhesions or 
stricture secondary to previous inflammation. One half 
of patients in this series had obstruction secondary to 
intussusception and the other half to an internal hernia 
from a band. In patients with a history of earlier episodes 
of rectal bleeding and abdominal pain, intermittent ob- 
struction secondary to intussusception must be consid- 
ered and occurred in three of our patients. 

The surgical management of a Meckel’s diverticulum 
requires either a diverticulectomy or, if the base of the 
diverticulum is wide or inflamed, a segmental small 
bowel resection. In addition, surgical resection should be 
considered in patients with bleeding because the bleeding 
ulcer may be in the adjacent ileum. In 80% of the cases in 
this series a simple diverticulectomy was done; an inci- 
dental appendectomy was performed concurrently in 75% 
of cases. There were no complications or deaths second- 
ary to surgery for a complicated Meckel’s diverticulum in 
this series. 

The surgical management of an incidentally discov- 



ered Meckel’s diverticulum remains controversial. It 
involves a balance of the risks of diverticulectomy against 
the risks of a patient becoming symptomatic sometime 
during his or her life and the added risk of removing a 
symptomatic diverticulum. Soltero estimated the life- 

Table 1 






Number of 























time risk of developing symptoms from a Meckel’s as 
4%. 17 Ectopic mucosa and the presence of a band corre- 
late with the development of symptoms. 12 Although it is 
difficult to recognize from gross, external inspection 
which diverticula are likely to contain ectopic mucosa, 
some clues include palpable nodules, peridiverticulitis, 
scarring, and inflammatory adhesions. 1 

In conclusion: 1) An incidentally discovered Meckel’s 
diverticulum should be removed if there is a band pres- 
ent, if there is a suggestion of ectopic mucosa, if scarring 
or inflammation is present, or if it will not jeopardize the 
intended operation at which the Meckel’s is discovered, 
2) Bleeding from a Meckel’s diverticulum is often ac- 
companied by abdominal pain and is often profuse 
enough to warrant transfusion, and 3) The morbidity 
and mortality associated with removing symptomatic 
Meckel’s diverticula in the pediatric surgical population 
is negligible. 


1. Mackey WC, Dineen P: A fifty-year experience with Meckel’s 
diverticulum. Surg Gynecol Obstei 1983;156:56-64. 

2. Moses WR: Meckel’s diverticulum: Report of two unusual cases. 
N Eng! J Med 1 947;237: 1 1 8-22. 

3. Michas CA, Cohen SE, Wolfman EF: Meckel’s diverticulum: 
Should it be excised incidentally at operation? A m J Surg 1975; 129: 

4. Hildanus F: Cited bv Neff G: Das Meckelsche Divertikel. Ergeb 
Chir Orthop 1937;30:227-315. 

5. Littre A: Observation sur une nouvelle espece de hernia. Hist Acad 
Royal Sci 1700;2:300-10. 

6. Meckel JF: Uber die Divertikel am Darmkanal. Arch der Physio 

7. Kuttner H: Ileus durch Intussusception eines Meckelschen Diver- 
tikels. Beitr Klin Chir 1898;21:289-98. 

8. Salzer H: Uber das offene Meckelsche Divertikel. Wien Klin 
Wochenschr 1904;17:614-17. 

9. Gramen K: Chronischen Ulcus in einem Meckelschen Divertikel 
mit Perforation und diffuser Peritonitis. Nord Med 1915,48:1. 

10. Christie A: Meckel’s diverticulum: A pathological study of 63 
cases. Am J Dis Child 1931;42:544-53. 

1 1. McParland FA. Kiesewetter WB: Meckel’s diverticulum in child- 
hood. Surg Gynecol Obsiet 1958;106:11-15. 

12. Artigas V, Calabulg R. Badia F, Rius X, Allende L, Jover J: 
Meckel’s diverticulum: Value of ectopic tissue. Am J Surg 1986; 

13. Rutherford RB, Akers DR: Meckel’s diverticulum: A review of 
148 pediatric patients, with special reference to the pattern of 
bleeding and to mesodiverticular vascular bands. Surgery 1966; 

14. Rosenthall L, Henry JN, Murphy DA. Freeman LM: Radioper- 
technetate imaging of the Meckel’s diverticulum. Radiology 1972; 

15. Jewett TC, Duszynski DO, Allen JE: The visualization of Meckel’s 
diverticulum with 99mTc-pertechnetate. Surgery 1970:68:567-70. 

16. Sfakianakis GN, Conway JJ: Detection of ectopic gastric mucosa 
in Meckel’s diverticulum and in other aberrations by scintography: 
Pathophysiology and ten year clinical experience. J Nucl Med 

17. Soltero MJ, Bill AH: The natural history of Meckel’s diverticulum 
and its relation to incidental removal: A study of 202 cases of 
diseased Meckel’s diverticulum found in King County, Washing- 
ton, over a fifteen year period. Am J Surg 1976;132:168-73. 

VOLUME 53, NO. 4 


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A Study of 13 Cases from the Connecticut Tumor Registry 


ABSTRACT— Thirteen cases of patients with dysger- 
minoma of the ovary, accrued from the Connecticut 
Tumor Registry from 1974-84, were reviewed. Seven of 
the 13 patients were stage I at the time of initial surgery. 
Two of these patients had a diagnosis of dysgerminoma 
arising within a gonadoblastoma. Five of the seven 
patients were treated with some form of adnexal surgery; 
one patient received adjuvant combination chemother- 
apy consisting of vincristine, dactinomycin, and cyclo- 
phosphamide (VAC) and another received radiation 
therapy. Two of the seven patients were treated with total 
abdominal hysterectomy and bilateral salpingo-oophor- 
ectomy (TAH/BSO) plus radiation therapy. One patient, 
whose tumor recurred after initial therapy with unilat- 
eral oophorectomy, was successfully treated with radia- 
tion therapy. Six patients had advanced disease at the 
time of initial surgery. One patient with stage II disease 
and three patients with stage III disease were treated with 
TAH/BSO plus radiation therapy. One patient with 
stage III disease was treated with unilateral adnexectomy 
plus combination chemotherapy consisting of vinblas- 
tine, bleomycin, dactinomycin, cyclophosphamide, and 
cisplatin (VAB-VI). One patient with stage IV disease 
was treated with decompressive laminectomy with tumor 
resection, removal of left pelvic mass, radiation therapy 
and adjuvant combination chemotherapy (VAC). In our 
series, no patient died from dysgerminoma (one patient 
died of an apparently unrelated cause). The role of radia- 
tion therapy in the treatment of advanced and recurrent 
dysgerminoma has been demonstrated. However, the 
use of combination chemotherapy has been playing an 
increasingly important role in patients treated with con- 
servative surgery in which preservation of fertility is a 

JOHN P. KOULOS, M.D., Assistant Professor of Obstetrics & 
Gynecology, Division of Gynecologic Oncology, Department of Ob- 
stetrics and Gynecology, College of Physicians and Surgeons, Colum- 
bia University, New York, NY. JAMES S. HOFFMAN, M.D., Asso- 
ciate Professor of Obstetrics & Gynecology, Division of Gynecologic 
Oncology, Department of Obstetrics and Gynecology, University of 
Connecticut Health Center, Farmington, CT. 

Presented at the New England Association of Gynecologic Oncolo- 
gists, June 25, 1988. 


G ERM cell tumors of the ovary account for approx- 
imately 15% to 20% of all ovarian neoplasms. The 
dysgerminoma is the most common malignant germ cell 
tumor of the ovary. Of the malignant tumors which 
develop in patients with gonadal dysgenesis, dysgermi- 
noma is the most prevalent. Patients with dysgerminoma 
carry a very favorable outlook, even with metastatic 
spread. Radiation therapy has been highly successful 
because of the tumor’s radiosensitivity. Recently, how- 
ever, conservative surgery, along with combination che- 
motherapy, has gained greater acceptance, especially for 
patients interested in preserving reproductive potential. 
In this study we examined the clinical management and 
treatment of cases of dysgerminoma of the ovary as 
recorded by a population-based cancer registry. 
Materials and Methods 

Case histories of female patients with pure dysgermi- 
noma of the ovary diagnosed from 1974-84 were reviewed 
from the Connecticut Tumor Registry (CTR) records. 
The CTR is a population-based registry that accrues 
data primarily from hospital and clinic records through- 
out the State of Connecticut with a small number of 
cases reported from death certificates and private physi- 
cians’ offices. Only cases of pure dysgerminoma were 
included in this study. Dysgerminomas containing ele- 
ments of other malignant germ cell tumors, such as 
immature teratoma, endodermal sinus tumor, or chorio- 
carcinoma, were excluded. Clinical data were collected 
from CTR records, hospital medical records, and cor- 
respondence with patients’ physicians. Follow-up infor- 
mation was obtained in all cases. 


Thirteen patients with dysgerminoma were collected 
from the CTR over an 1 1-year study period from 1974- 
84. The ages of the patients ranged from 15 to 38 years, 
with a median age of 21 years. 

Table 1 details the stage, treatment (surgery, chemo- 
therapy, radiation therapy), and the outcome of all 13 
patients. Seven of the 13 patients were stage I at the time 

VOLUME 53, NO. 4 







Table 1 

Treatment of Dysgerminoma 
Connecticut Tumor Registry (1974-84) 

(No. of Pts.) 


( 1 ) 


( 1 ) 

Treatment a 

(1) UO b 

(1) BSO 

(2) USO + RT 

(1) USO + VAC 

(2) TAH/BSO + RT 
(1) TAH/BSO + RT 

(3) TAH/BSO + RT 0 
(1) USO + VAB-VI 

(1) USO + decompressive 
laminectomy + RT + 

a No patients died from dysgerminoma. 

b Recurrence - susequently treated with TAH/BSO + RT = NED 
c One patient died at 35 months secondary to an apparently 
unrelated cause. 

UO = unilateral oophorectomy 
USO = unilateral salpingo-oophorectomy 
TAH = total abdominal hysterectomy 
BSO = bilateral salpingo-oophorectomy 
RT = radiation therapy 

VAC = vincristine, dactinomycin, and cyclophospamide 
VAB-VI = vinblastine, bleomyacin, dactinomycin, cyclophosphamide, 
and cisplatin 

of initial surgery. Two patients had a diagnosis of dys- 
germinoma arising within a gonadoblastoma. Four pa- 
tients were initially treated with some form of unilateral 
adnexal surgery (oophorectomy or salpingo-oophorec- 
tomy) with or without the addition of postoperative 
adjuvant combination chemotherapy or radiotherapy. 
One patient underwent bilateral salpingo-oophorectomy 
only. The two remaining patients underwent total ab- 
dominal hysterectomy and bilateral salpingo-oophorec- 
tomy (TAH/BSO) with the addition of postoperative 
whole abdominal-pelvic radiation therapy. In the stage 1 
group, all seven patients are alive with no evidence of 
disease. Recurrence occured in one patient who was 
initially treated with unilateral oophorectomy only. She 
was subsequently successfully treated with TAH, unilat- 
eral salpingo-oophorectomy (USO) and whole abdomi- 
nal radiotherapy and remains with no evidence of disease 

Six patients had advanced disease at the time of initial 
surgery. Four patients were treated with TAH / BSO plus 
radiation therapy. One patient who had stage III diagno- 
sis was treated with unilateral salpingo-oophorectomy 
plus combination chemotherapy consisting of vinblas- 
tine, bleomycin, dactinomycin, cyclophosphamide, and 
cisplatin (VAB-VI). One patient with stage IV disease 
was treated with decompressive laminectomy with tumor 
resection, removal of pelvic mass, radiation therapy plus 
combination chemotherapy consisting of vincristine, dac- 
tinomycin, and cyclophosphamide (VAC). One stage III 
patient, who had been treated with TAH/BSO plus 
radiotherapy remained NED for 35 months but subse- 
quently died of an apparently unrelated cause. 


Dysgerminoma is the most common type of malig- 
nant germ cell tumor, accounting for up to 2% of all 
ovarian malignancies. This neoplasm, which is similar to 
the testicular seminoma, is composed of germ cells that 
are similar to primordial germ cells. Microscopically, the 
tumor is composed of aggregates of large polygonal cells 
with vesicular nuclei containing one or more nucleoli and 
is often infiltrated by lymphocytes and foreign body 
giant cells. 1 In about 5% of dysgerminomas, syncytiotro- 
phoblastic giant cells, which are the source of increased 
levels of gonadotropin, may be present. 2 Dysgerminoma 
is the most prevalent type of malignant tumor arising in 
the patients with gonadal dysgenesis. 

The use of adjuvant radiotherapy over the past three 
decades has had a significant impact on the high cure rate 
for dysgerminoma. Lucraft reported a five-year survival 
rate of 85% in 33 cases of ovarian dysgerminoma between 
1943 and 1977; he emphasized the role of radiotherapy in 
advanced disease cases, and recommended reserving 
radiotherapy for recurrent disease in unilateral stage I 
disease. 3 In the series of Krepart, 31 of 36 patients 
received postoperative radiation therapy. Ninety-two 
percent receiving initial treatment at this institution and 
70% of those referred for treatment after recurrence 
survived with no evidence of disease. 4 

The role of conservative surgery with or without the 
use of adjuvant radiotherapy or chemotherapy has re- 
cently raised considerable controversy. In a review article 
by Thomas, 5 the results of treatment of 145 patients with 
stage I A disease from three large series were examined. 6 " 8 
When these patients were treated with conservative 
surgery consisting of unilateral oophorectomy with or 
without ipsilateral salpingectomy, 24% relapsed, but sal- 
vage therapy with radiation therapy was successful in 
65%. Their overall 1 0-year survival of 9 1 % was similar to 
the 85% 10-year survival in a group of 53 patients who 
initially received nonconservative therapy for stage IA 

For patients with advanced stage disease, the addition 
of radiotherapy had demonstrated success in several 
series. LaPolla reviewed the results of therapy in 50 
patients with stage III dysgerminoma compiled from 
seven series utilizing primary radiotherapy since 1976. 9 
He reported a death rate of 32% (16 patients: 15 from 
progressive disease and one from intestinal radionecro- 
sis). Four patients from our series with advanced disease 
were successfully managed with TAH/BSO plus radio- 

Much of the therapeutic considerations for dysgermi- 
noma have been based on prior experience with the 
testicular counterpart, seminoma. Chemotherapy has 
demonstrated good response rates in patients with ad- 
vanced seminoma, especially with cisplatin-containing 
regimens. Einhom utilized vinblastine, bleomycin, and 
cisplatin. 10 Memorial Hospital reported an 86% corn- 



plete remission in 28 patients with advanced seminoma 
utilizing VAB-VI (vinblastine, bleomycin, dactinomycin, 
cyclophosphamide, and cisplatin). 11 From our series, 
one patient with stage III was successfully treated with 
this chemotherapy regimen after conservative surgery 
(unilateral adnexectomy). Schwartz reported five patients 
with pure dysgerminoma from his series of malignant 
germ cell tumors. 12 Of interest was one patient (also 
reported in our series) who presented with lower extrem- 
ity paralysis and who underwent decompressive laminec- 
tomy at which metastatic dysgerminoma was found. 
After laparotomy revealed a dysgerminoma, the patient 
was successfully treated with radiation therapy to the 
pelvis and central nervous system sites and with VAC 
chemotherapy. Bianchi reported on 1 1 stage III dysger- 
minoma patients treated primarily with chemotherapy 
after surgery. 13 Of seven patients treated with doxoru- 
bicin and cyclophosphamide and five patients treated 
with displatin, vinblastine, and bleomycin (PVB), nine of 
12 patients achieved complete remission with the three 
remaining patients subsequently successfully treated with 
radiation therapy with or without PVB chemotherapy. 
Gershenson treated two patients with metastatic ovarian 
dysgerminoma successfully with PVB chemotherapy. 14 

Our recommendation for the treatment of dysgermi- 
noma would be conservative surgery with unilateral 
adnexectomy for properly staged IA patients. Chemo- 
therapy or radiotherapy may be withheld if the patient’s 
course can be carefully followed for possible recurrence. 
For cases of metastic dysgerminoma, aggressive surgical 
extirpation with radiotherapy has been shown to yield 
excellent results. However, an acceptable alternative in 
these patients who desire preservation of fertility would 
be a conservative surgical approach with combination 
chemotherapy. Second-look laparotomy to assess tumor 

status would be helpful in these patients in order to plan 
further radiotherapy and/or chemotherapy if necessary. 


1 . Kurman RJ, Norris HJ: Malignant germ cell tumors of the ovary. 
Human Pathology 1977;8:551-64. 

2. Zaloudek CJ, Tavassoli FA, Norris RJ: Dysgerminoma with syn- 
cytiotrophoblastic giant cells: A histologically and clinically dis- 
tinctive subtype of dysgerminoma. Am J Surg Pathol 198 1 ;5: 36 1 -7. 

3. Lucraft HH: A review of thirty-three cases of ovarian dysgermi- 
noma emphasizing the role of radiotherapy. Clin Radiol 1979; 

4. Krepart G, Smith JP. Rutledge F, Declos L: The treatment for 
dysgerminoma of the ovary. Cancer 1978;41:986-90. 

5. Thomas GM, Dembo AJ, Hacker NF, DePetrillo AD: Current 
therapy for dysgerminoma of the ovary. Obstet Gynecol 1987; 

6. Asadourian LA, Taylor HB: Dysgerminoma: An analysis of 105 
cases. Obstet Gynecol 1969;33:370-9. 

7. Gordon A, Lipton D, Woodruff JD: Dysgerminoma: A review of 
158 cases from the Emil Novak ovarian tumor registry. Obstet 
Gynecol 1981;58:497-504. 

8. Malkasian GD, Symmonds RE: Treatment of the unilateral en- 
capsulated ovarian dysgerminoma. Am J Obstet Gynecol 1964; 

9. LaPollaJP, Benda J, VigliottiAP, Anderson B: Dysgerminoma of 
the ovary. Obstet Gynecol 1987;69:859-64. 

10. Einhorn LH, Williams SD: Chemotherapy of disseminated semi- 
noma. Cancer Clin Trials 1980;3:307-13. 

1 1. Stanton GF, Bosl GJ, Whitmore WF, Herr H, Sogani P, Morse 
M, Golby RB: VAB-6 as initial treatment of patients with advanced 
seminoma. J Clin Oncol 1985;3:336-9. 

12. Schwartz PE: Combination chemotherapy in the management of 
ovarian germ cell malignancies. Obstet Gynecol 1984;64:564-72. 

13. Bianchi UA, Sartori E, Favalli G, Epis A, Vassena L, Bonazzi D: 
New trends in treatment of ovarian dysgerminoma. Gynecol Oncol 

14. Gershenson DM, Wharton JT, Kline RC, Larson DM, Kavanagh 
JJ, Rutledge FN: Chemotherapeutic complete remission in patients 
with metastatic ovarian dysgerminoma. Cancer 1986;58:2594-9. 

VOLUME 53, NO. 4 


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